Basic Information
| Provider Information | |||||||||
| NPI: | 1508442757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLAS | ||||||||
| FirstName: | MYRIAM | ||||||||
| MiddleName: | ST LOT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2346 DORA ST | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339015202 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1350 LEE BLVD | ||||||||
| Address2: | |||||||||
| City: | LEHIGH ACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339364846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393692163 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2021 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 9538014 | FL | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 03 | 05 | FL | MEDICAID |