Basic Information
| Provider Information | |||||||||
| NPI: | 1932136728 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLLO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BOURNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ANP05/ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1408 E MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022309336 | ||||||||
| FaxNumber: | 6022777824 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 E. INDIAN SCHOOL ROAD | ||||||||
| Address2: | RESEARCH SERVICE | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022775551 | ||||||||
| FaxNumber: | 6022122097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN018619 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.