Basic Information
| Provider Information | |||||||||
| NPI: | 1932424967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEEHAN | ||||||||
| FirstName: | COLETTE | ||||||||
| MiddleName: | SAINT MARYLIN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E WENDOVER AVE STE 311 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362726161 | ||||||||
| FaxNumber: | 3362302150 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 45TH ST STE 206 | ||||||||
| Address2: | |||||||||
| City: | MANGONIA PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618448354 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2010 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | ME117581 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0205X | 2021-02877 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 017213400 | 05 | FL | MEDICAID |