MEDICARE: ETIENNA COLEMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide	81-3262557	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780135020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETIENNA COLEMAN

Provider Business Mailing Address
First Line	:	3621 LOUISIANA AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-3509
Country	:	US
Telephone Number	:	314-550-2990
Fax Number	:

Provider Business Practice Location Address
First Line	:	3621 LOUISIANA AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-3509
Country	:	US
Telephone Number	:	314-550-2990
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2016
Last Update Date	:	12/30/2016

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Directions to “ ETIENNA COLEMAN ” Practice Location

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