1477074078 NPI number — MISS CARLA SUE COLLINS

Table of content: MISS CARLA SUE COLLINS (NPI 1477074078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477074078 NPI number — MISS CARLA SUE COLLINS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLINS
Provider First Name:
CARLA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
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:
1477074078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 S GRAHAM AVE APT 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62901-3377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-262-6283
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 VETERANS DRIVE
Provider Second Line Business Practice Location Address:
P.O. BOX 869
Provider Business Practice Location Address City Name:
HARRISBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62946-6294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-252-0377
Provider Business Practice Location Address Fax Number:
618-252-2389
Provider Enumeration Date:
07/05/2017

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: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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