Provider Demographics
NPI:1679347512
Name:COLUCCI, CHEYENNE DALY (APRN)
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:DALY
Last Name:COLUCCI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CHEYENNE
Other - Middle Name:MARIE
Other - Last Name:DALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:506 CASA SEVILLA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-4755
Mailing Address - Country:US
Mailing Address - Phone:352-256-1406
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-256-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9451089163W00000X
FLAPRN11026328363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121275700Medicaid