Provider Demographics
NPI:1972807774
Name:COLTART, MICHELLE ELIZABETH (LAC)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:COLTART
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4843 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1702
Mailing Address - Country:US
Mailing Address - Phone:619-392-0443
Mailing Address - Fax:
Practice Address - Street 1:3239 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1645
Practice Address - Country:US
Practice Address - Phone:619-546-4806
Practice Address - Fax:619-546-5326
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13330171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist