Healthcare Provider Details

I. General information

NPI: 1578934592
Provider Name (Legal Business Name): COLBY MCILVAINE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2015
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MOUNT WOOD RD
WHEELING WV
26003-2632
US

IV. Provider business mailing address

109 MOUNT WOOD RD
WHEELING WV
26003-2632
US

V. Phone/Fax

Practice location:
  • Phone: 304-233-2455
  • Fax: 304-233-6073
Mailing address:
  • Phone: 304-233-2455
  • Fax: 304-233-6073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number91474
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: