Provider Demographics
NPI:1609454883
Name:HANEY, COLLEEN ROSALIE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ROSALIE
Last Name:HANEY
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29826 HAUN RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6547
Mailing Address - Country:US
Mailing Address - Phone:951-679-7022
Mailing Address - Fax:
Practice Address - Street 1:1197 AIRPORT RD STE 2
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-6491
Practice Address - Country:US
Practice Address - Phone:023-508-0541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017043363LA2200X
DELP-0010723363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health