Provider Demographics
NPI:1689070021
Name:COLLINS, SHELIA
Entity Type:Individual
Prefix:
First Name:SHELIA
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELIA
Other - Middle Name:BONEY
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLANDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38748-3239
Mailing Address - Country:US
Mailing Address - Phone:662-827-0607
Mailing Address - Fax:
Practice Address - Street 1:105 DEER CREEK
Practice Address - Street 2:
Practice Address - City:ARCOLA
Practice Address - State:MS
Practice Address - Zip Code:38722-3239
Practice Address - Country:US
Practice Address - Phone:662-827-0607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA0600X261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800225357Medicaid