Healthcare Provider Details

I. General information

NPI: 1750730966
Provider Name (Legal Business Name): BRENDA R. COLLINS AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

IV. Provider business mailing address

510 4TH ST S
FARGO ND
58103-1914
US

V. Phone/Fax

Practice location:
  • Phone: 605-698-7606
  • Fax: 605-742-0182
Mailing address:
  • Phone: 701-476-7823
  • Fax: 701-476-7261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCP001226
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR32069
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: