Provider Demographics
NPI:1295894103
Name:PERSONETT, COLLEEN (OD)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:
Last Name:PERSONETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 RIDGEPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5737
Mailing Address - Country:US
Mailing Address - Phone:907-388-7507
Mailing Address - Fax:
Practice Address - Street 1:1867 AIRPORT WAY
Practice Address - Street 2:STE 150A
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4061
Practice Address - Country:US
Practice Address - Phone:907-452-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKA192152W00000X
PAOE008289T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U95650Medicare UPIN
K152650Medicare ID - Type Unspecified