Provider Demographics
NPI:1821555129
Name:COLBORN, SHANNON MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:COLBORN
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 1:330 WESTERN BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4383
Mailing Address - Country:US
Mailing Address - Phone:860-547-0306
Mailing Address - Fax:
Practice Address - Street 1:330 WESTERN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-547-0306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-23
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8101363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health