Provider Demographics
NPI:1649566415
Name:COLLURA, NICOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:COLLURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3687 TAMPA RD
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677
Mailing Address - Country:US
Mailing Address - Phone:813-471-0152
Mailing Address - Fax:
Practice Address - Street 1:4210 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:SCHNECKSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18078-2580
Practice Address - Country:US
Practice Address - Phone:610-769-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATOP008311224Z00000X
TX211496224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant