Provider Demographics
NPI:1972500536
Name:CHADDERTON, COLLEEN (RNC, MSN, CPNP)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:CHADDERTON
Suffix:
Gender:F
Credentials:RNC, MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2048
Mailing Address - Country:US
Mailing Address - Phone:517-780-9260
Mailing Address - Fax:517-780-9263
Practice Address - Street 1:760 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2048
Practice Address - Country:US
Practice Address - Phone:517-780-9260
Practice Address - Fax:517-780-9263
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704105291363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3200785-10Medicaid
MIQ04418OtherUPIN #
MIN81890003Medicare UPIN