Provider Demographics
NPI:1740994292
Name:DEL FAVA, COLLEEN KELLY (APNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:KELLY
Last Name:DEL FAVA
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:MULCAHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34700 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4500
Mailing Address - Country:US
Mailing Address - Phone:262-646-4411
Mailing Address - Fax:
Practice Address - Street 1:4555 W SCHROEDER DR
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-1475
Practice Address - Country:US
Practice Address - Phone:414-355-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI174832-030163W00000X
WI13528363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse