Healthcare Provider Details

I. General information

NPI: 1740893148
Provider Name (Legal Business Name): COLLEEN CHLOE MCCONNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KENYON AVE
WAKEFIELD RI
02879-4216
US

IV. Provider business mailing address

848 STARCREST ST
BREA CA
92821-2050
US

V. Phone/Fax

Practice location:
  • Phone: 401-782-8000
  • Fax:
Mailing address:
  • Phone: 714-335-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10025
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA62655
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01520
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: