Provider Demographics
NPI:1659427607
Name:WOLFORD, COLLEEN DASCHBACH (FNP)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:DASCHBACH
Last Name:WOLFORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:AGNES
Other - Last Name:WOLFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:426 GEMSTONE CT
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6055
Mailing Address - Country:US
Mailing Address - Phone:706-787-9122
Mailing Address - Fax:706-787-9116
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:EISENHOWER ARMY MEDICAL CENTER
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-2720
Practice Address - Fax:706-787-8176
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN