Provider Demographics
NPI:1790385029
Name:COLLIE, JAMES EDWARD (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:COLLIE
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 ROYAL GROVE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-8996
Mailing Address - Country:US
Mailing Address - Phone:386-506-6388
Mailing Address - Fax:
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-506-6388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009725363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care