Healthcare Provider Details

I. General information

NPI: 1982344214
Provider Name (Legal Business Name): TIFFANY COLBORN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date: 04/01/2022
Reactivation Date: 04/20/2022

III. Provider practice location address

405 RUSHING DR
HERRIN IL
62948-3730
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-3300
  • Fax: 618-993-0262
Mailing address:
  • Phone: 618-993-3300
  • Fax: 618-993-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209025019
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: