1902477656 NPI number — STALACIA COLLYMORE

Table of content: STALACIA COLLYMORE (NPI 1902477656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902477656 NPI number — STALACIA COLLYMORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLYMORE
Provider First Name:
STALACIA
Provider Middle Name:
Provider Name Prefix Text:
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:
1902477656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
226 GRAND CLUB PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34982-8124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-425-4922
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 27TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-4011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-218-1153
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2021

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: 106S00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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