Healthcare Provider Details

I. General information

NPI: 1790494136
Provider Name (Legal Business Name): MISS PRINCESS KOLLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 22ND AVE
MARION IA
52302-1623
US

IV. Provider business mailing address

2525 22ND AVE
MARION IA
52302-1623
US

V. Phone/Fax

Practice location:
  • Phone: 319-651-3737
  • Fax:
Mailing address:
  • Phone: 319-651-3737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: