Provider Demographics
NPI:1538162938
Name:HANNON, DIANE H (RD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:H
Last Name:HANNON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 NIMROD DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-1646
Mailing Address - Country:US
Mailing Address - Phone:978-369-0035
Mailing Address - Fax:978-369-0035
Practice Address - Street 1:2194 MAIN ST
Practice Address - Street 2:OFC 6
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3829
Practice Address - Country:US
Practice Address - Phone:978-505-5953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1653133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALD0169OtherBCBSMA LDN ANCILLARY PROV
MACA MT0722Medicare ID - Type UnspecifiedMNT PROVIDER