=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518096767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANN VIRAE COLLIE DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 N BROADWAY
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46970-1027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-266-8840
-----------------------------------------------------
Fax | 260-266-8849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11109 PARKVIEW PLAZA DR # 117
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 0102201775
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 0102201775
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 02002938A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------