Healthcare Provider Details

I. General information

NPI: 1376837690
Provider Name (Legal Business Name): MARJORIE M COYLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 CITY VIEW DR
EVANSTON WY
82930-5327
US

IV. Provider business mailing address

350 CITY VIEW DR
EVANSTON WY
82930-5327
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-7915
  • Fax: 307-789-6009
Mailing address:
  • Phone: 307-789-7915
  • Fax: 307-789-6009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: