Provider Demographics
NPI:1902803208
Name:COLELLA, JEAN MARIE (ANP)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MARIE
Last Name:COLELLA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MRS
Other - First Name:JEAN
Other - Middle Name:MARIE
Other - Last Name:DEFFNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:1050 GAIL GARDNER WAY STE 300
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1640
Practice Address - Country:US
Practice Address - Phone:928-717-5232
Practice Address - Fax:928-717-5238
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN090566163W00000X
AZAP1972363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP1972OtherAZ NP LIC