Provider Demographics
NPI:1356860514
Name:VILLARREAL, COLEEN MARY
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:MARY
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9912 82ND ST
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33777-1903
Mailing Address - Country:US
Mailing Address - Phone:703-867-1134
Mailing Address - Fax:
Practice Address - Street 1:6500 38TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1629
Practice Address - Country:US
Practice Address - Phone:703-341-4870
Practice Address - Fax:703-344-4707
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9194837363LF0000X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency