Healthcare Provider Details

I. General information

NPI: 1770073157
Provider Name (Legal Business Name): CAROLE STALEY COLLINS PHD,MSN,RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 ANNAPOLIS RD
BLADENSBURG MD
20710-1224
US

IV. Provider business mailing address

243 ANCHORAGE DRIVE
ANNAPOLIS MD
21409-6314
US

V. Phone/Fax

Practice location:
  • Phone: 443-282-5577
  • Fax: 410-706-0140
Mailing address:
  • Phone: 410-349-0229
  • Fax: 410-706-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR145852
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: