Provider Demographics
NPI:1568748986
Name:CLINE, COLLEEN HANNON (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:COLLEEN
Middle Name:HANNON
Last Name:CLINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:HANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8383 MILLICENT WAY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-5207
Mailing Address - Country:US
Mailing Address - Phone:318-797-6661
Mailing Address - Fax:318-795-8503
Practice Address - Street 1:8383 MILLICENT WAY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-5207
Practice Address - Country:US
Practice Address - Phone:318-797-6661
Practice Address - Fax:318-795-8512
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07541363A00000X
LAPA200506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant