1639255078 NPI number — MS. THEA S COLLIN MS,PNP,CS

Table of content: MS. THEA S COLLIN MS,PNP,CS (NPI 1639255078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639255078 NPI number — MS. THEA S COLLIN MS,PNP,CS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLIN
Provider First Name:
THEA
Provider Middle Name:
S
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS,PNP,CS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639255078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5105 COLUMBIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29526-8607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 BELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526-4113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-248-2727
Provider Business Practice Location Address Fax Number:
843-248-5107
Provider Enumeration Date:
10/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  APN780 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 364SP0807X , with the licence number: APN780 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: APN780 . This is a "LICENSE NO" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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