Provider Demographics
NPI:1275900029
Name:ROLLINS, MAYA SHANNON (CCMA)
Entity Type:Individual
Prefix:MS
First Name:MAYA
Middle Name:SHANNON
Last Name:ROLLINS
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37203 WEST TIMBERLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460
Mailing Address - Country:US
Mailing Address - Phone:504-252-1182
Mailing Address - Fax:
Practice Address - Street 1:900 WILKINSON ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3533
Practice Address - Country:US
Practice Address - Phone:985-624-4450
Practice Address - Fax:985-624-4461
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ3D8D5E5246RP1900X
LAW6R8Q5D7247200000X
LAY4X2G3P62472E0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAY4X2G3P6OtherCERTIFIED EKG TECHNICIAN
LAW6R8Q5D7OtherCERTIFIED CLINICAL MEDICAL ASSISTANT
LAZ3D8D5E5OtherCERTIFIED PHLEBOTOMY TECHNICIAN
LALA05334OtherCPR