Provider Demographics
NPI:1730665449
Name:COLBURN, DUSTY MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:DUSTY
Middle Name:MARIE
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 1:4900 KELLEY HWY
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72904-5000
Mailing Address - Country:US
Mailing Address - Phone:479-785-5700
Mailing Address - Fax:479-785-5708
Practice Address - Street 1:4900 KELLEY HWY
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-5000
Practice Address - Country:US
Practice Address - Phone:479-785-5700
Practice Address - Fax:479-785-5708
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005776363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137012001Medicaid