Provider Demographics
NPI:1912498460
Name:COLLIER, IVA RENEE (CHW)
Entity Type:Individual
Prefix:
First Name:IVA
Middle Name:RENEE
Last Name:COLLIER
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 O ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-1259
Mailing Address - Country:US
Mailing Address - Phone:410-800-3707
Mailing Address - Fax:
Practice Address - Street 1:60 O ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-1259
Practice Address - Country:US
Practice Address - Phone:202-271-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD407837172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC13493555Medicaid