Provider Demographics
NPI:1275394462
Name:BEARD, COLEY MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:COLEY
Middle Name:MICHELLE
Last Name:BEARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 S MAPLE PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-4644
Mailing Address - Country:US
Mailing Address - Phone:225-650-4341
Mailing Address - Fax:
Practice Address - Street 1:711 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4717
Practice Address - Country:US
Practice Address - Phone:918-207-0558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20100861164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse