Provider Demographics
NPI:1275875783
Name:COLBERT, ANGEL A (LPN)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:A
Last Name:COLBERT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7988 HEADWATER DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8070
Mailing Address - Country:US
Mailing Address - Phone:614-649-3576
Mailing Address - Fax:
Practice Address - Street 1:7988 HEADWATER DR
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-8070
Practice Address - Country:US
Practice Address - Phone:614-649-3576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 126439164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084172Medicaid