Provider Demographics
NPI:1902941586
Name:KOLASSA, KOLLEEN KAY (RN)
Entity Type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:KAY
Last Name:KOLASSA
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 1:1041 E SULLIVAN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-224-1607
Mailing Address - Fax:423-224-1640
Practice Address - Street 1:1041 E SULLIVAN ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-224-1607
Practice Address - Fax:423-224-1640
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000096928163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB58933Medicare UPIN
TN3911774Medicare ID - Type UnspecifiedMEDICARE # FOR KINGSPORT