Healthcare Provider Details

I. General information

NPI: 1831424043
Provider Name (Legal Business Name): ESSIE MCCOLLOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 N HIGHLAND ST 2A
MEMPHIS TN
38122-4544
US

IV. Provider business mailing address

475 N HIGHLAND ST 2A
MEMPHIS TN
38122-4544
US

V. Phone/Fax

Practice location:
  • Phone: 901-488-7848
  • Fax: 901-323-1868
Mailing address:
  • Phone: 901-488-7848
  • Fax: 901-323-1868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number021157058
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: