Provider Demographics
NPI:1760632053
Name:MCCOLLETT, MICHELLE KRYSTAL
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KRYSTAL
Last Name:MCCOLLETT
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 1:58 OLD COLONY AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2406
Mailing Address - Country:US
Mailing Address - Phone:617-268-1700
Mailing Address - Fax:617-268-1991
Practice Address - Street 1:58 OLD COLONY AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2406
Practice Address - Country:US
Practice Address - Phone:617-268-1700
Practice Address - Fax:617-268-1991
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program