Provider Demographics
NPI:1306474333
Name:ALLEN, COLLEEN MELISSA LEATHRUM (DO)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MELISSA LEATHRUM
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 MONUMENT AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-4905
Mailing Address - Country:US
Mailing Address - Phone:804-358-4904
Mailing Address - Fax:
Practice Address - Street 1:3602 MONUMENT AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-4905
Practice Address - Country:US
Practice Address - Phone:804-358-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102207723208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty