Provider Demographics
NPI:1336517978
Name:COLLAZO, JEANETTE (RN)
Entity type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 OLD MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-3262
Mailing Address - Country:US
Mailing Address - Phone:845-672-9351
Mailing Address - Fax:
Practice Address - Street 1:569 OLD MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-3262
Practice Address - Country:US
Practice Address - Phone:845-672-9351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY529962163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy