Provider Demographics
NPI:1245634997
Name:MARRI PORTIA COLLOM FNP PLLC
Entity type:Organization
Organization Name:MARRI PORTIA COLLOM FNP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FNP/ PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARRI
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLOM
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:303-775-3401
Mailing Address - Street 1:PO BOX 1307
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:CO
Mailing Address - Zip Code:80466-1307
Mailing Address - Country:US
Mailing Address - Phone:303-775-3401
Mailing Address - Fax:
Practice Address - Street 1:350 EAST ST
Practice Address - Street 2:#1307
Practice Address - City:NEDERLAND
Practice Address - State:CO
Practice Address - Zip Code:80466-5001
Practice Address - Country:US
Practice Address - Phone:303-775-3401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0990991-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39877833Medicaid