MEDICARE: DR. DIANE M. M. DELLAVALLE PHD, RDN, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DN001084	PA

General Provider Information

NPI Number	:	1629555222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE M. M. DELLAVALLE PHD, RDN, LDN

Provider Business Mailing Address
First Line	:	PO BOX 1133
Second Line	:
City	:	GOULDSBORO
State	:	PA
Zip	:	18424-1133
Country	:	US
Telephone Number	:	607-229-3683
Fax Number	:

Provider Business Practice Location Address
First Line	:	88 MOUNTAINSIDE DRIVE
Second Line	:
City	:	GOULDSBORO
State	:	PA
Zip	:	18424-1133
Country	:	US
Telephone Number	:	607-229-3683
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2018
Last Update Date	:	07/26/2018

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