1467713008 NPI number — COLEEN E O'BRIEN PNP

Table of content: COLEEN E O'BRIEN PNP (NPI 1467713008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467713008 NPI number — COLEEN E O'BRIEN PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BRIEN
Provider First Name:
COLEEN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
COLEEN
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467713008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 601067
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-1067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-631-0002
Provider Business Mailing Address Fax Number:
704-631-0002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 BLYTHE BLVD.
Provider Second Line Business Practice Location Address:
SUITE 200D
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28203-6215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-373-1813
Provider Business Practice Location Address Fax Number:
704-373-1813
Provider Enumeration Date:
05/30/2012

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: 363LP0200X , with the licence number:  RN173314 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: AP4492 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X , with the licence number: 300221 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 710871 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112725200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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