Provider Demographics
NPI:1487785846
Name:MCCOLLUM, KATHLEEN ANN (RN)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:YOUNGLUND
Other - Last Name:MCCOLLUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1025 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3307
Mailing Address - Country:US
Mailing Address - Phone:480-472-0562
Mailing Address - Fax:480-472-0796
Practice Address - Street 1:1025 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3307
Practice Address - Country:US
Practice Address - Phone:480-472-0562
Practice Address - Fax:480-472-0796
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ025557163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ648230Medicaid