Provider Demographics
NPI:1366468498
Name:STELLABOTTE, COLLEEN C (RN, MSN, CRNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:C
Last Name:STELLABOTTE
Suffix:
Gender:F
Credentials:RN, MSN, CRNP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:STELLABOTTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, MSN, CRNP
Mailing Address - Street 1:8 OAK PARK DR
Mailing Address - Street 2:STE3000
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1414
Mailing Address - Country:US
Mailing Address - Phone:781-280-1513
Mailing Address - Fax:
Practice Address - Street 1:501 S 54TH ST
Practice Address - Street 2:ACADEMIC ER SVCS - ER DEPT
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1900
Practice Address - Country:US
Practice Address - Phone:215-748-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN273433L, SP003540C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
021672JTKMedicare PIN
PAS43079Medicare UPIN
PA500008786Medicare PIN