Provider Demographics
NPI:1831353895
Name:COLBURN, MARYANNE L (RT)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:L
Last Name:COLBURN
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 PARK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 PARK RIDGE DR
Practice Address - Street 2:
Practice Address - City:RIVER RIDGE
Practice Address - State:LA
Practice Address - Zip Code:70123-1182
Practice Address - Country:US
Practice Address - Phone:504-738-5273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1951247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist