Provider Demographics
NPI:1619906161
Name:BROWN, COLEEN L (CRNA)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:L
Last Name:BROWN
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 1:5050 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5886
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-484-9603
Practice Address - Street 1:11420 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1729
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-484-9603
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704101472367500000X
IN28187556A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200961560Medicaid
IN058940A5Medicare PIN