Provider Demographics
NPI:1235402264
Name:COGBURN, DIANNE (RD, LDN, MPH)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:
Last Name:COGBURN
Suffix:
Gender:F
Credentials:RD, LDN, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 CADIZ RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-1618
Mailing Address - Country:US
Mailing Address - Phone:941-223-1422
Mailing Address - Fax:
Practice Address - Street 1:721 CADIZ RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-1618
Practice Address - Country:US
Practice Address - Phone:941-223-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 529133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered