Provider Demographics
NPI:1710083233
Name:TETZLAFF, COLLEEN (FNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:TETZLAFF
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1638
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-1638
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:222 AUBURN ST
Practice Address - Street 2:STE 103
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-6005
Practice Address - Country:US
Practice Address - Phone:207-699-3838
Practice Address - Fax:855-216-3778
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30344710Medicaid
ME432379199Medicaid
NH30344710Medicaid
MEP00751480Medicare PIN
MENP548702Medicare PIN