Provider Demographics
NPI:1881027241
Name:FLEMING, COLLEEN R (PMHNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:R
Last Name:FLEMING
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:1090 W PARK PL
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2785
Practice Address - Country:US
Practice Address - Phone:208-215-2005
Practice Address - Fax:844-807-3782
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010095243363LP0808X
ID10935112363LP0808X
OR202201642NP-PP363LP0808X
ID58380363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1881027241Medicaid
WA2105313Medicaid