Provider Demographics
NPI:1013026517
Name:COLLINS, KELLIE (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 SW YAMADA DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-8518
Mailing Address - Country:US
Mailing Address - Phone:772-336-2161
Mailing Address - Fax:
Practice Address - Street 1:4516 SW YAMADA DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-8518
Practice Address - Country:US
Practice Address - Phone:772-336-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1946582363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP1946582OtherLICENSE