Provider Demographics
NPI:1194146613
Name:WILSON, DIANA LEAH (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LEAH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 FAYETTEVILLE ST
Mailing Address - Street 2:2910
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1974
Mailing Address - Country:US
Mailing Address - Phone:512-666-7730
Mailing Address - Fax:
Practice Address - Street 1:301 FAYETTEVILLE ST
Practice Address - Street 2:2910
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-1974
Practice Address - Country:US
Practice Address - Phone:512-666-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004031133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered