Provider Demographics
NPI:1558993279
Name:DECOLLI, ROBERT III (CRNP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DECOLLI
Suffix:III
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7460 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1760
Practice Address - Country:US
Practice Address - Phone:901-763-0200
Practice Address - Fax:901-761-4002
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021499363L00000X
MS906328363L00000X
TN31566363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner