Healthcare Provider Details

I. General information

NPI: 1164050563
Provider Name (Legal Business Name): KELSEY RENEE COLLIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 HOLLISTER AVE STE 110
GOLETA CA
93111-2379
US

IV. Provider business mailing address

750 HIGHLAND AVE
MADISON WI
53705-2221
US

V. Phone/Fax

Practice location:
  • Phone: 805-683-0055
  • Fax:
Mailing address:
  • Phone: 847-340-5084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: