Provider Demographics
NPI:1750603114
Name:GUMM, COLLEEN M (APNP)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:M
Last Name:GUMM
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:11430 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1414 N TAYLOR DR
Practice Address - Street 2:SUITE 144
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1988
Practice Address - Country:US
Practice Address - Phone:920-457-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3970-033363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIMG 2114217OtherDEA NUMBER