Provider Demographics
NPI:1912387119
Name:LIPANOVICH, COLLEEN (FNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:LIPANOVICH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WEST BUNNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-466-0676
Mailing Address - Fax:805-466-4862
Practice Address - Street 1:5920 WEST MALL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4232
Practice Address - Country:US
Practice Address - Phone:805-466-0676
Practice Address - Fax:805-466-4862
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002478363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily