Provider Demographics
NPI:1104128651
Name:COLLINS, MISTIE HOLLY (APRN)
Entity type:Individual
Prefix:
First Name:MISTIE
Middle Name:HOLLY
Last Name:COLLINS
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8731 BANKERS ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-4240
Mailing Address - Country:US
Mailing Address - Phone:859-282-8840
Mailing Address - Fax:859-282-8830
Practice Address - Street 1:8731 BANKERS ST UNIT A
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4240
Practice Address - Country:US
Practice Address - Phone:859-282-8840
Practice Address - Fax:859-282-8830
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006752363LF0000X, 363L00000X
KY6752P363LF0000X
OHCOA.11948-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0052835Medicaid
KY7100167790Medicaid
KYP00954943OtherRAIL ROAD MEDICARE
KYP00920266OtherRAILROAD MEDICARE
OH0052835Medicaid