Provider Demographics
NPI:1093044471
Name:COLBERT, MONIQUE (APN)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:COLBERT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 1159
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3883
Mailing Address - Country:US
Mailing Address - Phone:312-942-5020
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 1159
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-942-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007585363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041308145OtherLICENSE NUMBER