Doctor Name: | COLLEEN M CANAVAN |
NPI Number: | 1205090644 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PA |
License Number: | 085000651 |
Business Practice Address: | 390 Maple Summit Rd Jerseyville, IL - 620522000 |
Business Phone Number: | 6184982101 |
Business Fax Number: | 6184988153 |
Mailing Address: | 390 Maple Summit Rd, JERSEYVILLE |
State: | IL |
Postal Code: | 620522000 |
Phone Number: | 6184982101 |
Fax Number: | 6184988153 |
NPI Enumeration Date: | 07/15/2008 |
NPI Last Update Date: | 12/30/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | 085000651 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |