Provider Demographics
NPI:1114064698
Name:COLLIER-BARSTAD, DEBORAH JANE (MSN)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:JANE
Last Name:COLLIER-BARSTAD
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:COLLIER-BARSTAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PNP
Mailing Address - Street 1:15753 PROMENADE AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15255 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2487
Practice Address - Country:US
Practice Address - Phone:734-285-3090
Practice Address - Fax:734-285-3095
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704158669363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI50-0-86-6148-0OtherBCBSM PIN
MI296-0240Medicaid