Healthcare Provider Details

I. General information

NPI: 1023755774
Provider Name (Legal Business Name): COLLEEN KOORN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN MACK

II. Dates (important events)

Enumeration Date: 05/15/2022
Last Update Date: 05/15/2022
Certification Date: 05/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 W MARINE VIEW DR STE C
EVERETT WA
98201-2098
US

IV. Provider business mailing address

12719 47TH DR NE
MARYSVILLE WA
98271-8634
US

V. Phone/Fax

Practice location:
  • Phone: 425-259-0212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61192894
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: