1306854757 NPI number — CAROLYN M. COLLINS ARNP

Table of content: MS. WANETA DESHON WILLIS-COOPER (NPI 1053584938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306854757 NPI number — CAROLYN M. COLLINS ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLINS
Provider First Name:
CAROLYN
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MERCER
Provider Other First Name:
CAROLYN
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306854757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 E KINCAID ST
Provider Second Line Business Mailing Address:
C/O CREDENTIALING
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98274-4127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-814-6724
Provider Business Mailing Address Fax Number:
360-428-6485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 E KINCAID ST
Provider Second Line Business Practice Location Address:
SKAGIT REGIONAL CLINICS
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98274-4127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-428-2592
Provider Business Practice Location Address Fax Number:
360-428-6470
Provider Enumeration Date:
08/03/2006

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: 363L00000X , with the licence number:  RN00141897 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: AP30005948 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9633553 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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