Provider Demographics
NPI:1912042755
Name:CHAMPLIN, COLLEEN (NP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:CHAMPLIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3433
Mailing Address - Country:US
Mailing Address - Phone:208-251-2328
Mailing Address - Fax:208-478-8500
Practice Address - Street 1:444 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2701
Practice Address - Country:US
Practice Address - Phone:208-478-5600
Practice Address - Fax:208-478-8500
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP516A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP50737Medicare UPIN