Healthcare Provider Details

I. General information

NPI: 1962793810
Provider Name (Legal Business Name): COLLEEN INGRID RITA NANTON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3460 OLD WASHINGTON RD SUITE 300
WALDORF MD
20602-3240
US

IV. Provider business mailing address

11350 MCCORMICK RD EXECUTIVE PLAZA 1, SUITE 501
HUNT VALLEY MD
21031-1002
US

V. Phone/Fax

Practice location:
  • Phone: 301-645-1523
  • Fax: 301-645-6812
Mailing address:
  • Phone: 301-645-1523
  • Fax: 301-645-6812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0004446
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: