Provider Demographics
NPI:1730533852
Name:BURIAN, CHARLENE ANN (MS RD CD IBCLC)
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:ANN
Last Name:BURIAN
Suffix:
Gender:F
Credentials:MS RD CD IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 TWISTED BRANCH PL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-3436
Mailing Address - Country:US
Mailing Address - Phone:260-436-3980
Mailing Address - Fax:
Practice Address - Street 1:3213 TWISTED BRANCH PL
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-3436
Practice Address - Country:US
Practice Address - Phone:260-436-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001225A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered