=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235853425
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. COURTNEY C COLOBRO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2022
-----------------------------------------------------
Last Update Date | 11/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 MIDWAY MEDICAL PARK
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37620-1653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-652-0260
-----------------------------------------------------
Fax | 423-652-0694
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2316 BRIARCLIFF RD
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37660-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-803-6618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 35682
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 175777
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------