Provider Demographics
NPI:1396851622
Name:COLLODI-SWART, SALLY J (AARN)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:COLLODI-SWART
Suffix:
Gender:F
Credentials:AARN
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:J
Other - Last Name:COLLODI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1900 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:PHYSICIANS IMMEDIATE CARE INC
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-398-4780
Mailing Address - Fax:772-398-1550
Practice Address - Street 1:1900 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE BLVD
Practice Address - State:FL
Practice Address - Zip Code:34951
Practice Address - Country:US
Practice Address - Phone:772-398-4780
Practice Address - Fax:772-398-1550
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN833182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP27914Medicare UPIN
FLY7539TMedicare ID - Type Unspecified