Provider Demographics
NPI:1295068427
Name:COLLINS, KATHLEEN M (GNP)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:COLLINS
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 DRIVING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1057
Mailing Address - Country:US
Mailing Address - Phone:315-359-2640
Mailing Address - Fax:
Practice Address - Street 1:1208 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1057
Practice Address - Country:US
Practice Address - Phone:315-359-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340736-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400008721Medicare PIN