Provider Demographics
NPI:1922509520
Name:COLLIE, JACLYN RAE (CRNP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:RAE
Last Name:COLLIE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SARAH JANE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35757-7739
Mailing Address - Country:US
Mailing Address - Phone:314-749-0001
Mailing Address - Fax:
Practice Address - Street 1:902 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2438
Practice Address - Country:US
Practice Address - Phone:256-216-9777
Practice Address - Fax:256-216-9776
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-153844363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily