=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194093476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN EVANSON HERR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2011
-----------------------------------------------------
Last Update Date | 09/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 GARDEN VIEW CT SUITE 102
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-2478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-436-8881
-----------------------------------------------------
Fax | 760-436-1022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28078 BAXTER RD STE 530
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-436-8881
-----------------------------------------------------
Fax | 760-436-1022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 11633
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 493591
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------