Provider Demographics
NPI:1760950505
Name:COLLINS, GAYLE (IP)
Entity Type:Individual
Prefix:MRS
First Name:GAYLE
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:IP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1331
Mailing Address - Country:US
Mailing Address - Phone:937-371-9941
Mailing Address - Fax:937-387-6085
Practice Address - Street 1:8717 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1331
Practice Address - Country:US
Practice Address - Phone:937-371-9941
Practice Address - Fax:937-387-6085
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X, 347C00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0242001Medicaid