Provider Demographics
NPI:1902419641
Name:COLLINS, KASANDRA DIANE
Entity Type:Individual
Prefix:MRS
First Name:KASANDRA
Middle Name:DIANE
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 1:2809 SANTA FE ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-8277
Mailing Address - Country:US
Mailing Address - Phone:417-622-9378
Mailing Address - Fax:
Practice Address - Street 1:2809 SANTA FE ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-8277
Practice Address - Country:US
Practice Address - Phone:417-622-9378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC1722090343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)