Provider Demographics
NPI:1790930006
Name:BALLBACH, COLLEEN R (NP)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:R
Last Name:BALLBACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:R
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC PALLIATIVE CARE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6469
Mailing Address - Fax:414-266-1761
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC PALLIATIVE CARE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6469
Practice Address - Fax:414-266-1761
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI144887363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790930006Medicaid
WI736011346Medicare PIN