Healthcare Provider Details

I. General information

NPI: 1790930006
Provider Name (Legal Business Name): COLLEEN R. BALLBACH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN R EVANS NP

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 08/27/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC PALLIATIVE CARE
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

CHILDREN'S SPECIALTY GROUP-CHILDREN'S WISCONSIN MILWAUK 9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-6469
  • Fax: 414-266-1761
Mailing address:
  • Phone: 414-266-3339
  • Fax: 414-266-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number144887
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3704-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: