Healthcare Provider Details

I. General information

NPI: 1376821959
Provider Name (Legal Business Name): KIMBERLY ANN COLLARD OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COLOSSEO CIR
LAS CRUCES NM
88012-9309
US

IV. Provider business mailing address

100 COLOSSEO CIR
LAS CRUCES NM
88012-9309
US

V. Phone/Fax

Practice location:
  • Phone: 575-993-8092
  • Fax: 866-528-1211
Mailing address:
  • Phone: 575-993-8092
  • Fax: 866-528-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number2822
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: