Provider Demographics
NPI:1508326323
Name:COLLAZO, TANYA MARIA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIA
Last Name:COLLAZO
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 1:32 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06607-1068
Mailing Address - Country:US
Mailing Address - Phone:203-685-0821
Mailing Address - Fax:203-916-7009
Practice Address - Street 1:32 3RD ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06607-1068
Practice Address - Country:US
Practice Address - Phone:203-685-0821
Practice Address - Fax:203-916-7009
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTHCA.0001351253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care