Provider Demographics
NPI:1851777155
Name:KOLLOCK, VIVIAN ANN
Entity Type:Individual
Prefix:MISS
First Name:VIVIAN
Middle Name:ANN
Last Name:KOLLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:VIVIAN
Other - Middle Name:ANN
Other - Last Name:KOLLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2115 WHITE FARM LN
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9715
Mailing Address - Country:US
Mailing Address - Phone:336-491-4057
Mailing Address - Fax:
Practice Address - Street 1:2115 WHITE FARM LN
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-9715
Practice Address - Country:US
Practice Address - Phone:336-491-4057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health