1508882580 NPI number — COLLEEN LUCIA HARTSELL PA-C

Table of content: COLLEEN LUCIA HARTSELL PA-C (NPI 1508882580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508882580 NPI number — COLLEEN LUCIA HARTSELL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARTSELL
Provider First Name:
COLLEEN
Provider Middle Name:
LUCIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JUST
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
LUCIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508882580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2153 DEPT 40339
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35287-9387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-271-0100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 STUART RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37312-4803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-476-2464
Provider Business Practice Location Address Fax Number:
423-476-1008
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0956 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4051092 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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