Basic Information
| Provider Information | |||||||||
| NPI: | 1396071361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANNESS | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LAW | ||||||||
| OtherFirstName: | COLLEEN | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LANE, STE 300 | ||||||||
| Address2: | ADVANCED DERMATOLOGY OF MICHIGAN | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 13450 EAST 12 MILE RD | ||||||||
| Address2: | ADVANCED DERMATOLOGY OF MICHIGAN, PC | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862195960 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2009 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.