Provider Demographics
NPI:1720563497
Name:HAESCHE, COLLEEN PATRICIA (PCW)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:PATRICIA
Last Name:HAESCHE
Suffix:
Gender:F
Credentials:PCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 FAIRVIEW DR.
Mailing Address - Street 2:STE A
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-5493
Mailing Address - Country:US
Mailing Address - Phone:775-684-5000
Mailing Address - Fax:775-687-1181
Practice Address - Street 1:RURAL CLINICS FERNLEY
Practice Address - Street 2:415 HIGHWAY 95A BUILDING I
Practice Address - City:FERNLEY
Practice Address - State:NV
Practice Address - Zip Code:89408-9261
Practice Address - Country:US
Practice Address - Phone:775-575-7744
Practice Address - Fax:775-575-7769
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NV171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1972501021Medicaid