Provider Demographics
NPI:1477896140
Name:O'BRIEN PODULKA, COLLEEN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:
Last Name:O'BRIEN PODULKA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1407
Mailing Address - Country:US
Mailing Address - Phone:484-351-8217
Mailing Address - Fax:
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:215-955-4226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010748363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily