Provider Demographics
NPI:1508031725
Name:COLLEY, HEATHER VILLA (RN, BSN)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:VILLA
Last Name:COLLEY
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 VANCE ST
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-9420
Mailing Address - Country:US
Mailing Address - Phone:304-855-4558
Mailing Address - Fax:304-855-3376
Practice Address - Street 1:506 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3306
Practice Address - Country:US
Practice Address - Phone:304-792-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52669163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0060164000Medicaid