Provider Demographics
NPI:1598197014
Name:COLLINS, WENDA L
Entity Type:Individual
Prefix:MR
First Name:WENDA
Middle Name:L
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-8058
Mailing Address - Country:US
Mailing Address - Phone:912-571-6942
Mailing Address - Fax:
Practice Address - Street 1:713 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-8058
Practice Address - Country:US
Practice Address - Phone:912-571-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA81116172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver