Basic Information
Provider Information | |||||||||
NPI: | 1396011813 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | MARIE | ||||||||
MiddleName: | V | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4211 VAN DYKE RD | ||||||||
Address2: | SUITE 205 | ||||||||
City: | LUTZ | ||||||||
State: | FL | ||||||||
PostalCode: | 335588002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8132299292 | ||||||||
FaxNumber: | 8132299293 | ||||||||
Practice Location | |||||||||
Address1: | 3200 HERNE BAY CT | ||||||||
Address2: |   | ||||||||
City: | LAND O LAKES | ||||||||
State: | FL | ||||||||
PostalCode: | 346388152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3868641641 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2012 | ||||||||
LastUpdateDate: | 11/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP-9268967 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | APRN9268967 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1396011813 | 01 | FL | NPI | OTHER |