Provider Demographics
NPI:1457661100
Name:COLBURN, DIANE A (DTR/CDN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:A
Last Name:COLBURN
Suffix:
Gender:F
Credentials:DTR/CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223
Mailing Address - Country:US
Mailing Address - Phone:716-400-8871
Mailing Address - Fax:
Practice Address - Street 1:226 MOORE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14223
Practice Address - Country:US
Practice Address - Phone:716-400-8871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004758-1133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist