Provider Demographics
NPI:1366968786
Name:MOORE, COLEEN MICHELE
Entity type:Individual
Prefix:MISS
First Name:COLEEN
Middle Name:MICHELE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-7539
Mailing Address - Country:US
Mailing Address - Phone:620-786-8826
Mailing Address - Fax:
Practice Address - Street 1:108 S PINE ST
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2739
Practice Address - Country:US
Practice Address - Phone:620-786-8826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator