Healthcare Provider Details

I. General information

NPI: 1851894471
Provider Name (Legal Business Name): THOMAS PERRY COLLEY APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 12/02/2023
Certification Date: 12/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 BUFFALO RD
BENTON KY
42025-7356
US

IV. Provider business mailing address

301 BUFFALO RD
BENTON KY
42025-7356
US

V. Phone/Fax

Practice location:
  • Phone: 270-703-9697
  • Fax:
Mailing address:
  • Phone: 270-703-9697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3012152
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: