Healthcare Provider Details

I. General information

NPI: 1205029345
Provider Name (Legal Business Name): CHRISTIANN MICHELLE COLLINS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5211 NE GLISAN ST BLDG C
PORTLAND OR
97213-3052
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-6628
  • Fax:
Mailing address:
  • Phone: 503-215-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberLD-D-10182758
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10182758
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI00001998
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: