Provider Demographics
NPI:1477709541
Name:COLIN, CASEY R (DCN, RDN, LN, CNSC)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:R
Last Name:COLIN
Suffix:
Gender:F
Credentials:DCN, RDN, LN, CNSC
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:R
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4822 BOAT LANDING DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3693
Mailing Address - Country:US
Mailing Address - Phone:605-695-1485
Mailing Address - Fax:
Practice Address - Street 1:4822 BOAT LANDING DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3693
Practice Address - Country:US
Practice Address - Phone:605-695-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0351133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered