Basic Information
| Provider Information | |||||||||
| NPI: | 1023005725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLQUITT | ||||||||
| FirstName: | LETHA | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 GALLERIA OAKS DR | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755034625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145390 | ||||||||
| FaxNumber: | 9032237089 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 JAMES BOWIE DR | ||||||||
| Address2: | |||||||||
| City: | NEW BOSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755702335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145950 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 541559 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200327160A | 05 | OK | MEDICAID |