Provider Demographics
NPI:1396217261
Name:COLBURN, ANGELA MARIE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:COLBURN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 RESURRECTION DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4735
Mailing Address - Country:US
Mailing Address - Phone:419-449-2324
Mailing Address - Fax:
Practice Address - Street 1:2751 DEBARR RD STE 250
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-6818
Practice Address - Country:US
Practice Address - Phone:419-494-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK123498133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered