Provider Demographics
NPI:1164095550
Name:REILLY, COLEEN (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 SW 18TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-3058
Mailing Address - Country:US
Mailing Address - Phone:814-644-8299
Mailing Address - Fax:
Practice Address - Street 1:672 SW PRIMA VISTA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1820
Practice Address - Country:US
Practice Address - Phone:772-905-2560
Practice Address - Fax:772-336-8341
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11014451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily