Provider Demographics
NPI:1407645351
Name:COLLEY, TOMBONG
Entity type:Individual
Prefix:
First Name:TOMBONG
Middle Name:
Last Name:COLLEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4494 SODA CREEK RD APT C
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1024
Mailing Address - Country:US
Mailing Address - Phone:920-479-3996
Mailing Address - Fax:920-479-3996
Practice Address - Street 1:4494 SODA CREEK RD APT C
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-1024
Practice Address - Country:US
Practice Address - Phone:920-479-3996
Practice Address - Fax:920-479-3996
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care