Provider Demographics
NPI:1154590503
Name:LOUDENBACK, DIANA R (RD/LD)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:R
Last Name:LOUDENBACK
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S MAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4909
Mailing Address - Country:US
Mailing Address - Phone:817-920-6738
Mailing Address - Fax:817-920-6743
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-920-6734
Practice Address - Fax:817-920-6743
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04141133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered