Provider Demographics
NPI:1780230474
Name:COLLINS, OTO-OBONG
Entity Type:Individual
Prefix:
First Name:OTO-OBONG
Middle Name:
Last Name:COLLINS
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 1:1907 OAK CREEK RD APT 212
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-5857
Mailing Address - Country:US
Mailing Address - Phone:504-701-5607
Mailing Address - Fax:
Practice Address - Street 1:3932 HIGHWAY 90 W
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:LA
Practice Address - Zip Code:70094-2648
Practice Address - Country:US
Practice Address - Phone:504-436-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203681363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care