Healthcare Provider Details

I. General information

NPI: 1124382403
Provider Name (Legal Business Name): MICHELE NICOLE COLLINS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2012
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E DOUGLAS RD STE 406
MISHAWAKA IN
46545
US

IV. Provider business mailing address

707 CEDAR ST
SOUTH BEND IN
46617-2054
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-6580
  • Fax:
Mailing address:
  • Phone: 574-335-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036139645
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01073777B
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11017396A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01073777A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: