Basic Information
Provider Information | |||||||||
NPI: | 1306854757 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | CAROLYN | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MERCER | ||||||||
OtherFirstName: | CAROLYN | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ARNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1400 E KINCAID ST | ||||||||
Address2: | C/O CREDENTIALING | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982744127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608146724 | ||||||||
FaxNumber: | 3604286485 | ||||||||
Practice Location | |||||||||
Address1: | 1400 E KINCAID ST | ||||||||
Address2: | SKAGIT REGIONAL CLINICS | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982744127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604282592 | ||||||||
FaxNumber: | 3604286470 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2006 | ||||||||
LastUpdateDate: | 08/26/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN00141897 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | AP30005948 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 9633553 | 05 | WA |   | MEDICAID |