Provider Demographics
NPI:1790107100
Name:COLONNA, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COLONNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CHESAPEAKE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-6607
Mailing Address - Country:US
Mailing Address - Phone:443-303-8987
Mailing Address - Fax:443-715-0020
Practice Address - Street 1:101 CHESAPEAKE BLVD STE B
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921
Practice Address - Country:US
Practice Address - Phone:443-303-8987
Practice Address - Fax:443-245-3464
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant