Healthcare Provider Details

I. General information

NPI: 1164095550
Provider Name (Legal Business Name): COLEEN REILLY MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

672 SW PRIMA VISTA BLVD STE 102
PORT ST LUCIE FL
34983-1820
US

IV. Provider business mailing address

2313 SW 18TH TER
CAPE CORAL FL
33991-3058
US

V. Phone/Fax

Practice location:
  • Phone: 772-905-2560
  • Fax: 772-336-8341
Mailing address:
  • Phone: 814-644-8299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11014451
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: