Provider Demographics
NPI:1669729208
Name:COLLINS, MALLORY J (ARNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:J
Last Name:COLLINS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:J
Other - Last Name:KEBBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 13833
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-3833
Mailing Address - Country:US
Mailing Address - Phone:352-265-7999
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP0265872363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006473100Medicaid
FLHD179ZMedicare PIN