Provider Demographics
NPI:1023755774
Name:KOORN, COLLEEN (ARNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:KOORN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12719 47TH DR NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-8634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1716 W MARINE VIEW DR STE C
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2098
Practice Address - Country:US
Practice Address - Phone:425-259-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-15
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61192894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP61192894OtherWASHINGTON STATE DEPARTMENT OF HEALTH
F06211752OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD