Provider Demographics
NPI:1003984204
Name:BALCH, COLEEN (MSN RN-BC ANP AACC)
Entity Type:Individual
Prefix:MS
First Name:COLEEN
Middle Name:
Last Name:BALCH
Suffix:
Gender:F
Credentials:MSN RN-BC ANP AACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 BONSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-9628
Mailing Address - Country:US
Mailing Address - Phone:315-695-6759
Mailing Address - Fax:
Practice Address - Street 1:3946 BONSTEAD RD
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-9628
Practice Address - Country:US
Practice Address - Phone:315-695-6759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301300363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC0141Medicare ID - Type Unspecified