Healthcare Provider Details

I. General information

NPI: 1386741536
Provider Name (Legal Business Name): MS. COLLEEN BENNETT COBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/23/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 45TH ST KIMMEL BLDG
WEST PALM BEACH FL
33407-2413
US

IV. Provider business mailing address

100 MACARTHUR CSWY
MIAMI BEACH FL
33139-5101
US

V. Phone/Fax

Practice location:
  • Phone: 561-844-5255
  • Fax: 561-844-5245
Mailing address:
  • Phone: 305-535-4542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108683
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: