Healthcare Provider Details

I. General information

NPI: 1710206107
Provider Name (Legal Business Name): COLLEEN GILLILAND CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 3RD ST SUITE 100
BEAVER PA
15009-2333
US

IV. Provider business mailing address

274 3RD ST SUITE 100
BEAVER PA
15009-2333
US

V. Phone/Fax

Practice location:
  • Phone: 724-774-2942
  • Fax: 724-770-7943
Mailing address:
  • Phone: 724-774-2942
  • Fax: 724-770-7943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP010831
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: