Provider Demographics
NPI:1932136728
Name:COLLO, MARY BOURNE (ANP05/)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BOURNE
Last Name:COLLO
Suffix:
Gender:F
Credentials:ANP05/
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1408 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2358
Mailing Address - Country:US
Mailing Address - Phone:602-230-9336
Mailing Address - Fax:602-277-7824
Practice Address - Street 1:650 E. INDIAN SCHOOL ROAD
Practice Address - Street 2:RESEARCH SERVICE
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1892
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:602-212-2097
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZRN018619363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health