Provider Demographics
NPI:1679066948
Name:COLBURN, MARY (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COLBURN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1711
Practice Address - Country:US
Practice Address - Phone:203-239-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007605363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily