Provider Demographics
NPI:1144255175
Name:COLLISTER, VICKI (ANP)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:COLLISTER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:KAY
Other - Last Name:COLLISTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP
Mailing Address - Street 1:PO BOX 3178
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3178
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-4620
Practice Address - Fax:503-215-4846
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087000014N3163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
S76479Medicare UPIN