Provider Demographics
NPI:1467400564
Name:WALSH, COLLEEN R (ARNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:R
Last Name:WALSH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:JENKINS
Mailing Address - State:KY
Mailing Address - Zip Code:41537-0472
Mailing Address - Country:US
Mailing Address - Phone:606-832-2171
Mailing Address - Fax:606-832-2943
Practice Address - Street 1:9480 HIGHWAY 805
Practice Address - Street 2:
Practice Address - City:JENKINS
Practice Address - State:KY
Practice Address - Zip Code:41537-8182
Practice Address - Country:US
Practice Address - Phone:606-832-2171
Practice Address - Fax:606-832-2943
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2790P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1089841OtherARNP
KY2790POtherNURSE PRACTITIONER
KY2790POtherNURSE PRACTITIONER
KY3397925Medicare ID - Type UnspecifiedMEDICARE