Provider Demographics
NPI:1679968481
Name:COLLINS, MARY (NUTRITIONIST/CHES)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:NUTRITIONIST/CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5701
Mailing Address - Country:US
Mailing Address - Phone:541-244-2197
Mailing Address - Fax:
Practice Address - Street 1:1837 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5701
Practice Address - Country:US
Practice Address - Phone:541-244-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS109133N00000X
174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No174H00000XOther Service ProvidersHealth Educator