Provider Demographics
NPI:1598069544
Name:PICKENS, COLONIA
Entity type:Individual
Prefix:MRS
First Name:COLONIA
Middle Name:
Last Name:PICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 BAPTIST CAMPGROUND RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-8036
Mailing Address - Country:US
Mailing Address - Phone:205-333-7695
Mailing Address - Fax:205-339-7506
Practice Address - Street 1:6901 BAPTIST CAMPGROUND RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-8036
Practice Address - Country:US
Practice Address - Phone:205-333-7695
Practice Address - Fax:205-339-7506
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor