Provider Demographics
NPI:1619295425
Name:COLBERT FAMILY HEALTH AND WELLNESS, LLC
Entity Type:Organization
Organization Name:COLBERT FAMILY HEALTH AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARQUETTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MS,APRN, PMHNP-BC
Authorized Official - Phone:937-529-4376
Mailing Address - Street 1:2580 SHILOH SPRINGS RD STE B
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2100
Mailing Address - Country:US
Mailing Address - Phone:937-529-4376
Mailing Address - Fax:937-529-4538
Practice Address - Street 1:2580 SHILOH SPRINGS RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-2151
Practice Address - Country:US
Practice Address - Phone:937-529-4376
Practice Address - Fax:937-529-4538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-10322363LF0000X
363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1891932208OtherINDIVIDUAL NPI