Provider Demographics
NPI:1831346964
Name:COLONEL, CLOVER MARJORIE (RN)
Entity type:Individual
Prefix:
First Name:CLOVER
Middle Name:MARJORIE
Last Name:COLONEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5046
Mailing Address - Country:US
Mailing Address - Phone:336-222-8052
Mailing Address - Fax:336-222-8091
Practice Address - Street 1:1040 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5046
Practice Address - Country:US
Practice Address - Phone:336-222-8052
Practice Address - Fax:336-222-8091
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225000000X
NC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795167Medicaid