Healthcare Provider Details

I. General information

NPI: 1851383244
Provider Name (Legal Business Name): NICOLE LEE COLLMAN RN, NP, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. NICOLE LEE WILSON

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1779 W YOSEMITE AVE YOSEMITE BUILDING, SUITE 200
MANTECA CA
95337-5112
US

IV. Provider business mailing address

505 PARNASSUS AVE STE. M195
SAN FRANCISCO CA
94122
US

V. Phone/Fax

Practice location:
  • Phone: 209-825-2485
  • Fax: 209-825-2499
Mailing address:
  • Phone: 415-353-2873
  • Fax: 415-353-2528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP15718
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SX0106X
TaxonomyOccupational Health Clinical Nurse Specialist
License NumberCNS 2249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: