Provider Demographics
NPI:1588308738
Name:COLLIS, GRACE RENAE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:RENAE
Last Name:COLLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 YUKON AVE
Mailing Address - Street 2:
Mailing Address - City:WAR
Mailing Address - State:WV
Mailing Address - Zip Code:24892-7067
Mailing Address - Country:US
Mailing Address - Phone:304-875-3915
Mailing Address - Fax:
Practice Address - Street 1:867 YUKON AVE
Practice Address - Street 2:
Practice Address - City:WAR
Practice Address - State:WV
Practice Address - Zip Code:24892-7067
Practice Address - Country:US
Practice Address - Phone:304-875-3915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant