Provider Demographics
NPI:1285614875
Name:COLGROVE, SUSAN R (CRNP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:COLGROVE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 VERNON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4041
Mailing Address - Country:US
Mailing Address - Phone:706-884-2691
Mailing Address - Fax:706-845-7314
Practice Address - Street 1:1805 VERNON RD
Practice Address - Street 2:SUITE B
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4041
Practice Address - Country:US
Practice Address - Phone:706-884-2691
Practice Address - Fax:706-845-7314
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN019428 NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBBHFMedicare ID - Type Unspecified
GAS11915Medicare UPIN