Provider Demographics
NPI:1639255078
Name:COLLIN, THEA S (MS,PNP,CS)
Entity Type:Individual
Prefix:MS
First Name:THEA
Middle Name:S
Last Name:COLLIN
Suffix:
Gender:F
Credentials:MS,PNP,CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:907 BELL ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4113
Practice Address - Country:US
Practice Address - Phone:843-248-2727
Practice Address - Fax:843-248-5107
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN780363LP0200X, 364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Not Answered364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAPN780OtherLICENSE NO