Provider Demographics
NPI:1043469398
Name:MAZZONI, COLLEEN T (CRNA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:T
Last Name:MAZZONI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:T
Other - Last Name:MCGOVERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 8500
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-8500
Mailing Address - Country:US
Mailing Address - Phone:302-709-4497
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:1505 W SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6912
Practice Address - Country:US
Practice Address - Phone:302-709-4497
Practice Address - Fax:302-733-0854
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR10764400367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered