Provider Demographics
NPI:1023626124
Name:COLLINWOOD FAMILY CARE, LLC
Entity type:Organization
Organization Name:COLLINWOOD FAMILY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAYSHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:931-724-4628
Mailing Address - Street 1:105 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:COLLINWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:38450-4696
Mailing Address - Country:US
Mailing Address - Phone:931-724-4628
Mailing Address - Fax:931-724-4705
Practice Address - Street 1:105 3RD AVE N
Practice Address - Street 2:
Practice Address - City:COLLINWOOD
Practice Address - State:TN
Practice Address - Zip Code:38450-4696
Practice Address - Country:US
Practice Address - Phone:931-724-4628
Practice Address - Fax:931-724-4705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-15
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ004852Medicaid
TNQ060911Medicaid