Provider Demographics
NPI:1205020112
Name:COLLINS, SHIRLEY M (LPN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:M
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:M
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:5048
Mailing Address - Street 1:3830 S CUSHMAN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7530
Mailing Address - Country:US
Mailing Address - Phone:907-455-5304
Mailing Address - Fax:907-455-1460
Practice Address - Street 1:3830 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7530
Practice Address - Country:US
Practice Address - Phone:907-455-5304
Practice Address - Fax:907-455-1460
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5048164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0157Medicaid
AKK0000WCHCPMedicare PIN