Provider Demographics
NPI:1417787128
Name:MELANCON, DIANE (ND13468)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MELANCON
Suffix:
Gender:F
Credentials:ND13468
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 SWILLEY RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33567-3255
Mailing Address - Country:US
Mailing Address - Phone:813-310-3831
Mailing Address - Fax:
Practice Address - Street 1:1316 SWILLEY RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33567-3255
Practice Address - Country:US
Practice Address - Phone:813-310-3831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND13468133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist