Provider Demographics
NPI:1043255367
Name:KEANE-MULLOOLY, COLLEEN ANNE (RNC,MS,WHNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANNE
Last Name:KEANE-MULLOOLY
Suffix:
Gender:F
Credentials:RNC,MS,WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-5904
Mailing Address - Country:US
Mailing Address - Phone:608-347-2297
Mailing Address - Fax:
Practice Address - Street 1:302 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5904
Practice Address - Country:US
Practice Address - Phone:608-347-2297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2232-033207VG0400X
WI2232-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI68820-0006Medicare ID - Type UnspecifiedMEDICARE