Provider Demographics
NPI:1013294610
Name:IKEM, COLETTE C (MSN, CNM)
Entity Type:Individual
Prefix:MRS
First Name:COLETTE
Middle Name:C
Last Name:IKEM
Suffix:
Gender:F
Credentials:MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7989
Mailing Address - Country:US
Mailing Address - Phone:970-336-1500
Mailing Address - Fax:970-336-1505
Practice Address - Street 1:1715 61ST AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-7989
Practice Address - Country:US
Practice Address - Phone:970-336-1500
Practice Address - Fax:970-336-1505
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0163872163W00000X
COAPN.0170020-CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO319797YLB8Medicare PIN