Healthcare Provider Details

I. General information

NPI: 1063347128
Provider Name (Legal Business Name): COLLEEN MARIE ILLSLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 HIOAKS RD STE B
RICHMOND VA
23225-4072
US

IV. Provider business mailing address

2307 POATES DR
HENRICO VA
23228-3023
US

V. Phone/Fax

Practice location:
  • Phone: 804-272-5814
  • Fax:
Mailing address:
  • Phone: 860-387-9612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024197815
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: