Provider Demographics
NPI:1013552140
Name:COLCHADO, CLARISA BALLARTA (FNP)
Entity Type:Individual
Prefix:
First Name:CLARISA
Middle Name:BALLARTA
Last Name:COLCHADO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5887 ADAMS ST # A
Mailing Address - Street 2:
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-2043
Mailing Address - Country:US
Mailing Address - Phone:323-206-2734
Mailing Address - Fax:
Practice Address - Street 1:433 192ND TANK BN ROAD
Practice Address - Street 2:BLDG 853
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-3149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95010873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95010873OtherTRICARE INSURANCE- MILITARY