Healthcare Provider Details

I. General information

NPI: 1124396288
Provider Name (Legal Business Name): MARY JEANETTE COLLINS ATC, LATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CENTRAL METHODIST SQ
FAYETTE MO
65248-1104
US

IV. Provider business mailing address

614 S MAIN ST
BROOKFIELD MO
64628-2341
US

V. Phone/Fax

Practice location:
  • Phone: 660-248-6289
  • Fax:
Mailing address:
  • Phone: 660-734-2083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2010019646
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: