Healthcare Provider Details

I. General information

NPI: 1326131665
Provider Name (Legal Business Name): KOLLEEN BURNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

IV. Provider business mailing address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

V. Phone/Fax

Practice location:
  • Phone: 319-376-2134
  • Fax: 319-376-2188
Mailing address:
  • Phone: 319-376-2134
  • Fax: 319-376-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-105825
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4236
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1326131665
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier036105825
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 3
Identifier132131665
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK BLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: