Provider Demographics
NPI:1558375550
Name:COLLA, JUDITH (CNM)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:COLLA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WALNUT ST
Mailing Address - Street 2:SUITE 925
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3323
Mailing Address - Country:US
Mailing Address - Phone:215-829-8000
Mailing Address - Fax:
Practice Address - Street 1:601 WALNUT ST
Practice Address - Street 2:SUITE 925
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3323
Practice Address - Country:US
Practice Address - Phone:215-829-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW0080552367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015913390001Medicaid
R06563Medicare UPIN
PA191551Medicare PIN