MEDICARE: COLBERT FAMILY HEALTH AND WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	NP-10322	OH
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1891932208	OTHER	OH	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1619295425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLBERT FAMILY HEALTH AND WELLNESS, LLC

Provider Business Mailing Address
First Line	:	2580 SHILOH SPRINGS RD STE B
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45426-2100
Country	:	US
Telephone Number	:	937-529-4376
Fax Number	:	937-529-4538

Provider Business Practice Location Address
First Line	:	2580 SHILOH SPRINGS RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45426-2151
Country	:	US
Telephone Number	:	937-529-4376
Fax Number	:	937-529-4538

Authorized Official
Title or Position	:	OWNER
Name	:	MARQUETTA D COLBERT
Credential	:	MS,APRN, PMHNP-BC
Telephone Number	:	937-529-4376

Provider Enumeration Date	:	05/04/2010
Last Update Date	:	03/20/2022

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