Healthcare Provider Details

I. General information

NPI: 1679066948
Provider Name (Legal Business Name): MARY COLBURN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N MAIN STREET EXT
WALLINGFORD CT
06492-2400
US

IV. Provider business mailing address

850 N MAIN STREET EXT
WALLINGFORD CT
06492-2400
US

V. Phone/Fax

Practice location:
  • Phone: 203-626-4203
  • Fax: 203-626-1624
Mailing address:
  • Phone: 203-626-4203
  • Fax: 203-626-1624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number007605
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: