Provider Demographics
NPI:1396071361
Name:JANNESS, COLLEEN (PA-C)
Entity type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:JANNESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:LAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LANE, STE 300
Mailing Address - Street 2:ADVANCED DERMATOLOGY OF MICHIGAN
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:13450 EAST 12 MILE RD
Practice Address - Street 2:ADVANCED DERMATOLOGY OF MICHIGAN, PC
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088
Practice Address - Country:US
Practice Address - Phone:586-219-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant