Provider Demographics
NPI:1750626099
Name:COLLINS, DIANE (RD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:COLLINS
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 1:718 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-7815
Mailing Address - Country:US
Mailing Address - Phone:734-240-8400
Mailing Address - Fax:734-240-4424
Practice Address - Street 1:700 STEWART RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-5304
Practice Address - Country:US
Practice Address - Phone:734-240-1813
Practice Address - Fax:734-240-1892
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI720866133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered