Provider Demographics
NPI:1265463749
Name:COLLINS, KATHLEEN (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 HOGBACK RD STE 5A
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9750
Mailing Address - Country:US
Mailing Address - Phone:734-263-2400
Mailing Address - Fax:734-773-3471
Practice Address - Street 1:36475 5 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1971
Practice Address - Country:US
Practice Address - Phone:734-655-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704136003367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA104198986Medicaid
MIR66783Medicare UPIN
MA104198986Medicaid
MIN12210016Medicare ID - Type Unspecified