MEDICARE: MENNETTE J COLON CSA

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	246ZC0007X	Surgical Assistant
2	171M00000X	Case Manager/Care Coordinator		FL

General Provider Information

NPI Number	:	1780967976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MENNETTE J COLON CSA

Provider Business Mailing Address
First Line	:	1970 SW GLENDALE ST.
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34987
Country	:	US
Telephone Number	:	561-866-7572
Fax Number	:

Provider Business Practice Location Address
First Line	:	1970 SW GLENDALE ST.
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34987
Country	:	US
Telephone Number	:	561-866-7572
Fax Number	:

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

Provider Enumeration Date	:	09/23/2011
Last Update Date	:	08/14/2012

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