Provider Demographics
NPI:1902476583
Name:ALBERT, COLLETTE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:COLLETTE
Middle Name:MARIE
Last Name:ALBERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-4007
Mailing Address - Country:US
Mailing Address - Phone:708-714-7957
Mailing Address - Fax:
Practice Address - Street 1:345 COMPTON RD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130
Practice Address - Country:US
Practice Address - Phone:615-895-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN5188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ080207Medicaid