Provider Demographics
NPI:1790297448
Name:KOLOSKI, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KOLOSKI
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 1:776 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01034-9705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38 MULBERRY ST # 204
Practice Address - Street 2:PO BOX 313
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053
Practice Address - Country:US
Practice Address - Phone:413-727-3882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN216962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily