Healthcare Provider Details

I. General information

NPI: 1972500536
Provider Name (Legal Business Name): COLLEEN CHADDERTON RNC, MSN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 W FRANKLIN ST
JACKSON MI
49201-2048
US

IV. Provider business mailing address

760 W FRANKLIN ST
JACKSON MI
49201-2048
US

V. Phone/Fax

Practice location:
  • Phone: 517-780-9260
  • Fax: 517-780-9263
Mailing address:
  • Phone: 517-780-9260
  • Fax: 517-780-9263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704105291
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: