Provider Demographics
NPI:1508882580
Name:HARTSELL, COLLEEN LUCIA (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:LUCIA
Last Name:HARTSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:LUCIA
Other - Last Name:JUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2153 DEPT 40339
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-9387
Mailing Address - Country:US
Mailing Address - Phone:706-271-0100
Mailing Address - Fax:
Practice Address - Street 1:104 STUART RD NE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4803
Practice Address - Country:US
Practice Address - Phone:423-476-2464
Practice Address - Fax:423-476-1008
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4051092Medicaid
TNP66040Medicare UPIN
TN36883462Medicare PIN
TN4051092Medicaid
TN3688346Medicare PIN