Basic Information
Provider Information | |||||||||
NPI: | 1508967159 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | DEBRA | ||||||||
MiddleName: | COBB | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 670 GLEN ALLAN CV | ||||||||
Address2: |   | ||||||||
City: | COLLIERVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 380173702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9018547118 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5823 HIGHWAY 22 | ||||||||
Address2: |   | ||||||||
City: | MICHIE | ||||||||
State: | TN | ||||||||
PostalCode: | 383575175 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9013771011 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2006 | ||||||||
LastUpdateDate: | 02/24/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN55526 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | APN5664 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 3731594 | 05 | TN |   | MEDICAID |