Provider Demographics
NPI:1821228453
Name:LINGLEY, COLLEEN ANNE (RD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANNE
Last Name:LINGLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:ANNE
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1050 N SAN FRANCISCO ST
Practice Address - Street 2:SUITE B
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3259
Practice Address - Country:US
Practice Address - Phone:928-214-3737
Practice Address - Fax:928-214-3837
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ961594133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZTAX IDOther45-4464070
AZ447638Medicaid
AZZ199063Medicare PIN
AZZ194924Medicare PIN
AZTAX IDOther45-4464070