Provider Demographics
NPI:1932325644
Name:COLCLESSER, FELICIA ANNE (NP)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:ANNE
Last Name:COLCLESSER
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 1:4131 N WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1821
Mailing Address - Country:US
Mailing Address - Phone:260-436-7255
Mailing Address - Fax:
Practice Address - Street 1:5909 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1159
Practice Address - Country:US
Practice Address - Phone:260-432-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001217B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily