Provider Demographics
NPI:1679320667
Name:COLLINS, SHANARA
Entity type:Individual
Prefix:
First Name:SHANARA
Middle Name:
Last Name:COLLINS
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 1:5561 BOLERO WAY
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-3553
Mailing Address - Country:US
Mailing Address - Phone:678-760-0609
Mailing Address - Fax:
Practice Address - Street 1:411 MAXHAM RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-2903
Practice Address - Country:US
Practice Address - Phone:678-760-0609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO0992561744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management