Provider Demographics
NPI:1639404007
Name:COLLOM, MARRI PORTIA (NP-C)
Entity Type:Individual
Prefix:
First Name:MARRI
Middle Name:PORTIA
Last Name:COLLOM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MARRI
Other - Middle Name:PORTIA
Other - Last Name:COLLOM-DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 1307
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:CO
Mailing Address - Zip Code:80466-1307
Mailing Address - Country:US
Mailing Address - Phone:303-775-3401
Mailing Address - Fax:
Practice Address - Street 1:1013 TWIN SISTERS RD
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:CO
Practice Address - Zip Code:80466-9600
Practice Address - Country:US
Practice Address - Phone:303-775-3401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORXN.0100789-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner