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 1:515 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4324
Mailing Address - Country:US
Mailing Address - Phone:904-253-2720
Mailing Address - Fax:
Practice Address - Street 1:515 W 6TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4324
Practice Address - Country:US
Practice Address - Phone:904-253-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9654688163WW0101X
FL11029274367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO319797YLB8Medicare PIN