Provider Demographics
NPI:1063089548
Name:MORRIS, DIANE BLAIR (RDN, LD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:BLAIR
Last Name:MORRIS
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 SUSAN LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2056
Mailing Address - Country:US
Mailing Address - Phone:678-389-1016
Mailing Address - Fax:
Practice Address - Street 1:160 SUSAN LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-2056
Practice Address - Country:US
Practice Address - Phone:678-389-1016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003256133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty