Provider Demographics
NPI:1215713631
Name:COLLINS, MACY MICHELLE
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:MICHELLE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACY
Other - Middle Name:MICHELLE
Other - Last Name:GOLLADAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 SOUTH CEDAR STREET
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-1838
Practice Address - Country:US
Practice Address - Phone:217-774-4400
Practice Address - Fax:217-774-6445
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN286821363LP0808X
IL209030396363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health