Healthcare Provider Details

I. General information

NPI: 1235941998
Provider Name (Legal Business Name): MS. MICHELLE MARIE COLVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 ALAMEDA DEL PRADO STE 103
NOVATO CA
94949-6698
US

IV. Provider business mailing address

201 ALAMEDA DEL PRADO STE 103
NOVATO CA
94949-6698
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-6964
  • Fax:
Mailing address:
  • Phone: 628-301-1607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-IDBJTS
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: