Provider Demographics
NPI:1245430941
Name:SHIRLEY, COLLETTE ANNE
Entity Type:Individual
Prefix:
First Name:COLLETTE
Middle Name:ANNE
Last Name:SHIRLEY
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 1:29I SPARROW RD
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3101
Mailing Address - Country:US
Mailing Address - Phone:760-277-4726
Mailing Address - Fax:
Practice Address - Street 1:4845 FRAZEE RD APT 701
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-6834
Practice Address - Country:US
Practice Address - Phone:760-277-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA228543164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse