=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790174167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY CHRISTINE COLLINS NMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2015
-----------------------------------------------------
Last Update Date | 01/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42211 N 41ST DR. #A109
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-399-8222
-----------------------------------------------------
Fax | 623-455-8872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42211 N 41ST DR. #A109
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-399-8222
-----------------------------------------------------
Fax | 623-455-8872
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 06-964
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------