Provider Demographics
NPI:1356431050
Name:REILLY, COLLEEN K (RN, APN)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:K
Last Name:REILLY
Suffix:
Gender:F
Credentials:RN, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 COOPER PLZ
Mailing Address - Street 2:SUITE 502
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1438
Mailing Address - Country:US
Mailing Address - Phone:856-968-7433
Mailing Address - Fax:856-968-8366
Practice Address - Street 1:4 PLAZA DR
Practice Address - Street 2:SUITE 402
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2747
Practice Address - Country:US
Practice Address - Phone:856-270-4040
Practice Address - Fax:856-270-4044
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJNR79808363L00000X
NJNN79808363L00000X
PARN322533L363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ038817Medicare ID - Type Unspecified
P15033Medicare UPIN