Healthcare Provider Details

I. General information

NPI: 1770548018
Provider Name (Legal Business Name): JENNIFER DIANE COLLINS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CENTRAL AVE BATES COLLEGE DEPARTMENT OF ATHLETICS
LEWISTON ME
04240-6042
US

IV. Provider business mailing address

25 MARSTON ST APT 301
LEWISTON ME
04240-6170
US

V. Phone/Fax

Practice location:
  • Phone: 207-786-8258
  • Fax: 207-755-5959
Mailing address:
  • Phone: 207-577-0780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT266
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: