Provider Demographics
NPI:1578934592
Name:MCILVAINE, COLBY (CRNA)
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:
Last Name:MCILVAINE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MOUNT WOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2632
Mailing Address - Country:US
Mailing Address - Phone:304-233-2455
Mailing Address - Fax:304-233-6073
Practice Address - Street 1:109 MOUNT WOOD RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-2632
Practice Address - Country:US
Practice Address - Phone:304-233-2455
Practice Address - Fax:304-233-6073
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV91474367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered