Provider Demographics
NPI:1407208481
Name:COLLINS, NICOLE RIST (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RIST
Last Name:COLLINS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7709 GAYLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-7131
Mailing Address - Country:US
Mailing Address - Phone:518-774-8389
Mailing Address - Fax:
Practice Address - Street 1:8316 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6702
Practice Address - Country:US
Practice Address - Phone:704-547-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2478152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist