Healthcare Provider Details

I. General information

NPI: 1376219550
Provider Name (Legal Business Name): COLT NEYREY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 12/07/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 GLEN COVE DR
ROCKPORT ME
04856-4272
US

IV. Provider business mailing address

14224 S LAKESHORE DR
COVINGTON LA
70435-5776
US

V. Phone/Fax

Practice location:
  • Phone: 207-301-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number240061
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: