Provider Demographics
NPI:1801195953
Name:WALLA, COLLEEN MARIE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:WALLA
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8063 E 134TH PL
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-8488
Mailing Address - Country:US
Mailing Address - Phone:303-882-1440
Mailing Address - Fax:
Practice Address - Street 1:10065 E HARVARD AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-5968
Practice Address - Country:US
Practice Address - Phone:303-614-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO182499163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse