Provider Demographics
NPI:1508249038
Name:ENEBOE, COLETTE
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:ENEBOE
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 1:1015 S VAL VISTA DR UNIT 27
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5674
Mailing Address - Country:US
Mailing Address - Phone:602-920-4041
Mailing Address - Fax:
Practice Address - Street 1:1015 S VAL VISTA DR UNIT 27
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5674
Practice Address - Country:US
Practice Address - Phone:602-920-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0999314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility