Provider Demographics
NPI:1790494136
Name:KOLLIE, PRINCESS
Entity Type:Individual
Prefix:MISS
First Name:PRINCESS
Middle Name:
Last Name:KOLLIE
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 1:2525 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-1623
Mailing Address - Country:US
Mailing Address - Phone:319-651-3737
Mailing Address - Fax:
Practice Address - Street 1:2525 22ND AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-1623
Practice Address - Country:US
Practice Address - Phone:319-651-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA251S00000X
311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No251S00000XAgenciesCommunity/Behavioral Health