Basic Information
| Provider Information | |||||||||
| NPI: | 1568636165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILTON | ||||||||
| FirstName: | COLETTE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TILTON | ||||||||
| OtherFirstName: | COLETTE | ||||||||
| OtherMiddleName: | DOUGLAS | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038831626 | ||||||||
| FaxNumber: | 6038819914 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038831626 | ||||||||
| FaxNumber: | 6038819914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 013838-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 30342439 | 05 | NH | MEDICAID |