Provider Demographics
NPI:1124748678
Name:COLLINS, GRISELDA (IDC)
Entity type:Individual
Prefix:
First Name:GRISELDA
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 VANESSA DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2653
Mailing Address - Country:US
Mailing Address - Phone:415-867-3349
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE BLDG 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-7000
Practice Address - Country:US
Practice Address - Phone:161-953-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA11247486781710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program