MEDICARE: LACIE L FEDEWA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	4704254325	MI
2	363LF0000X	Family Nurse Practitioner	APN.0993372-NP	CO

General Provider Information

NPI Number	:	1760764732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACIE L FEDEWA NP

Provider Business Mailing Address
First Line	:	15101 E ILIFF AVE STE 140
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80014-4548
Country	:	US
Telephone Number	:	720-878-7055
Fax Number	:	720-390-5188

Provider Business Practice Location Address
First Line	:	2997 BROADMOOR VALLEY RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4405
Country	:	US
Telephone Number	:	719-355-7333
Fax Number	:	719-465-2015

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2011
Last Update Date	:	06/18/2025

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