Provider Demographics
NPI:1124443726
Name:COLLIEN, COURTNEY M
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:M
Last Name:COLLIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:M
Other - Last Name:LEITERITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2725 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1513
Mailing Address - Country:US
Mailing Address - Phone:920-223-7600
Mailing Address - Fax:
Practice Address - Street 1:889 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2933
Practice Address - Country:US
Practice Address - Phone:920-367-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI166270363LA2200X
WI5691363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health