Healthcare Provider Details

I. General information

NPI: 1326363953
Provider Name (Legal Business Name): PHYLLIS-CARMEN REBECCA COLBERT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

V. Phone/Fax

Practice location:
  • Phone: 410-701-4547
  • Fax:
Mailing address:
  • Phone: 410-701-4547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR185937
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: