Healthcare Provider Details

I. General information

NPI: 1689154882
Provider Name (Legal Business Name): KATHIE ANN COLVILLE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MEDI PARK DR STE 2048
AMARILLO TX
79106-2109
US

IV. Provider business mailing address

30 FAIRWAY DR
CANYON TX
79015-1810
US

V. Phone/Fax

Practice location:
  • Phone: 806-353-2101
  • Fax:
Mailing address:
  • Phone: 806-683-9965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number755437
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: