Healthcare Provider Details

I. General information

NPI: 1679664759
Provider Name (Legal Business Name): JOHN KOLLENBERG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WESTERN BAPTIST HOSPITAL 2501 KENTUCKY AVENUE
PADUCAH KY
42003
US

IV. Provider business mailing address

2507 BROADWAY
PADUCAH KY
42001
US

V. Phone/Fax

Practice location:
  • Phone: 270-575-2100
  • Fax:
Mailing address:
  • Phone: 270-442-8228
  • Fax: 270-442-9566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3003521
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: