Provider Demographics
NPI:1649685926
Name:COLLAZOS WOOLNOUGH, YAIRY MARCELA
Entity type:Individual
Prefix:
First Name:YAIRY
Middle Name:MARCELA
Last Name:COLLAZOS WOOLNOUGH
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 1:1080 SW 46TH AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-0998
Mailing Address - Country:US
Mailing Address - Phone:542-089-8297
Mailing Address - Fax:
Practice Address - Street 1:444 NW 1ST AVE APT 403
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-8204
Practice Address - Country:US
Practice Address - Phone:754-208-9829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2019-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
FLRBT-17-38869106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009870100Medicaid