Provider Demographics
NPI:1023826468
Name:COLCLOUGH, EVONDA (LPN, HWC)
Entity type:Individual
Prefix:MRS
First Name:EVONDA
Middle Name:
Last Name:COLCLOUGH
Suffix:
Gender:F
Credentials:LPN, HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 SORRENTO DR
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-8665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 SORRENTO DR
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-8665
Practice Address - Country:US
Practice Address - Phone:321-917-3775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA-3787309171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach