Healthcare Provider Details

I. General information

NPI: 1669106647
Provider Name (Legal Business Name): ANDREW LANE COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25201 E. 78 HWY
INDEPENDENCE MO
64056
US

IV. Provider business mailing address

25201 E. 78 HWY
INDEPENDENCE MO
64056
US

V. Phone/Fax

Practice location:
  • Phone: 816-796-7307
  • Fax: 816-796-7305
Mailing address:
  • Phone: 816-796-7307
  • Fax: 816-796-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number121079
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: