Provider Demographics
NPI:1417137571
Name:KOLESIAK, AMY LAUREN (NP-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LAUREN
Last Name:KOLESIAK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10565 CIVIC CENTER DR BLDG SUITE165
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3853
Mailing Address - Country:US
Mailing Address - Phone:909-985-2211
Mailing Address - Fax:909-985-2244
Practice Address - Street 1:10565 CIVIC CENTER DR BLDG SUITE165
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3853
Practice Address - Country:US
Practice Address - Phone:909-985-2211
Practice Address - Fax:909-985-2244
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010259363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty