Provider Demographics
NPI:1558451187
Name:COLLIE, MARY JO (FNP C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:COLLIE
Suffix:
Gender:F
Credentials:FNP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 GRAPEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BASTIAN
Mailing Address - State:VA
Mailing Address - Zip Code:24314-4547
Mailing Address - Country:US
Mailing Address - Phone:276-688-4331
Mailing Address - Fax:276-688-4336
Practice Address - Street 1:12301 GRAPEFIELD RD
Practice Address - Street 2:
Practice Address - City:BASTIAN
Practice Address - State:VA
Practice Address - Zip Code:24314-4547
Practice Address - Country:US
Practice Address - Phone:276-688-4331
Practice Address - Fax:276-688-4336
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165860363LF0000X
WV55352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7101185000Medicaid
VA010053552Medicaid
WV7101185000Medicaid
VA010053552Medicaid