Basic Information
| Provider Information | |||||||||
| NPI: | 1821228453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINGLEY | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURKE | ||||||||
| OtherFirstName: | COLLEEN | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | PAYER CREDENTIALING | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282136235 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 N SAN FRANCISCO ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282143737 | ||||||||
| FaxNumber: | 9282143837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2009 | ||||||||
| LastUpdateDate: | 03/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 961594 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | TAX ID | 01 | AZ | 45-4464070 | OTHER | 447638 | 05 | AZ | MEDICAID |