Provider Demographics
NPI:1497347298
Name:SCULLIN, COLLEEN THERESA (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:COLLEEN
Middle Name:THERESA
Last Name:SCULLIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:COLLEEN
Other - Middle Name:THERESA
Other - Last Name:SCULLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:275 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2005
Mailing Address - Country:US
Mailing Address - Phone:440-826-2221
Mailing Address - Fax:
Practice Address - Street 1:275 EASTLAND RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2005
Practice Address - Country:US
Practice Address - Phone:440-826-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH50.007034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant