Basic Information
| Provider Information | |||||||||
| NPI: | 1346541562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLASS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3926 NEW VISION DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602661401 | ||||||||
| FaxNumber: | 2604585734 | ||||||||
| Practice Location | |||||||||
| Address1: | 11141 PARKVIEW PLAZA DR STE 305B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604256770 | ||||||||
| FaxNumber: | 2604256789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2010 | ||||||||
| LastUpdateDate: | 05/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 37000931A | IN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.