Healthcare Provider Details

I. General information

NPI: 1841273497
Provider Name (Legal Business Name): COLLEEN SKY BAUCOM-PRO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN SKY BAUCOM-SLAVIN RD

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 STOCKTON BLVD 3RD FLOOR
SACRAMENTO CA
95817-1418
US

IV. Provider business mailing address

2039 ALTA LOMA ST
DAVIS CA
95616-0713
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-7260
  • Fax:
Mailing address:
  • Phone: 916-233-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number944951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: