Provider Demographics
NPI:1245992353
Name:O'BRIEN, COLLEEN ANN (RD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANN
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 TREASURE HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH KENT
Mailing Address - State:CT
Mailing Address - Zip Code:06785-1412
Mailing Address - Country:US
Mailing Address - Phone:917-468-8444
Mailing Address - Fax:
Practice Address - Street 1:119 TREASURE HILL RD
Practice Address - Street 2:
Practice Address - City:SOUTH KENT
Practice Address - State:CT
Practice Address - Zip Code:06785-1412
Practice Address - Country:US
Practice Address - Phone:917-468-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1096546133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1096546OtherAND