Provider Demographics
NPI:1164006144
Name:DILLON, COLLETTE R
Entity Type:Individual
Prefix:
First Name:COLLETTE
Middle Name:R
Last Name:DILLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 EXECUTIVE PARK DR STE 5
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3634
Mailing Address - Country:US
Mailing Address - Phone:954-694-0211
Mailing Address - Fax:
Practice Address - Street 1:2625 EXECUTIVE PARK DR STE 5
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3634
Practice Address - Country:US
Practice Address - Phone:954-694-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012851363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health