Healthcare Provider Details

I. General information

NPI: 1043255367
Provider Name (Legal Business Name): COLLEEN ANNE KEANE-MULLOOLY RNC,MS,WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 N JACKSON ST
MILWAUKEE WI
53202-5904
US

IV. Provider business mailing address

302 N JACKSON ST
MILWAUKEE WI
53202-5904
US

V. Phone/Fax

Practice location:
  • Phone: 608-347-2297
  • Fax:
Mailing address:
  • Phone: 608-347-2297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2232-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number2232-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: