Healthcare Provider Details

I. General information

NPI: 1154303477
Provider Name (Legal Business Name): GERALDINE ROSE MCCOLLUM ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9680 SPENCER MOUNTAIN RD S
SPRING VALLEY CA
91977-3436
US

IV. Provider business mailing address

9680 SPENCER MOUNTAIN RD
SPRING VALLEY CA
91977-3436
US

V. Phone/Fax

Practice location:
  • Phone: 619-203-1654
  • Fax:
Mailing address:
  • Phone: 619-203-1654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13044
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: