Provider Demographics
NPI:1841273497
Name:BAUCOM-PRO, COLLEEN SKY (RD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:SKY
Last Name:BAUCOM-PRO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:SKY
Other - Last Name:BAUCOM-SLAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2039 ALTA LOMA ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-0713
Mailing Address - Country:US
Mailing Address - Phone:916-233-6110
Mailing Address - Fax:
Practice Address - Street 1:2221 STOCKTON BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1418
Practice Address - Country:US
Practice Address - Phone:916-734-7260
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA944951133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered