Basic Information
| Provider Information | |||||||||
| NPI: | 1407169626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECCLESTON | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EARSING | ||||||||
| OtherFirstName: | COLLEEN | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 227 THORN AVE | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141272600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166622040 | ||||||||
| FaxNumber: | 7166620019 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145691326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857860220 | ||||||||
| FaxNumber: | 5857863631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2010 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 415322 | NY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.