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General NPI Number Information
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NPI Number | 1104339811
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Entity Type | Individual
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Provider Name | STACIE COLELLO
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Gender | Female
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Dates
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Enumeration Date | 11/16/2017
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Last Update Date | 11/16/2017
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Provider Practice Location Address
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Address Line | 802 HIGHWAY 119 SOUTH
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City | SPRINGFIELD
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State | GA
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Zip | 31329
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Country | US
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Telephone | 912-754-6484
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Fax |
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Provider Business Mailing Address
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Address Line | 3229 GA HIGHWAY 119 N
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City | PEMBROKE
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State | GA
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Zip | 31321-5829
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN175700
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License Number State | GA
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