Provider Demographics
NPI:1255987830
Name:OSBORNE, COLETTE
Entity type:Individual
Prefix:MRS
First Name:COLETTE
Middle Name:
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2263 PIKEWOOD LN SW # NA
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1612
Mailing Address - Country:US
Mailing Address - Phone:404-933-0405
Mailing Address - Fax:
Practice Address - Street 1:2263 PIKEWOOD LN SW # NA
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1612
Practice Address - Country:US
Practice Address - Phone:404-933-0405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-10
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052341476172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty