Healthcare Provider Details

I. General information

NPI: 1538257027
Provider Name (Legal Business Name): PAULETT R WENTWORTH CERTIFIED FITTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 CENTENNIAL BLVD # 106
COLORADO SPRINGS CO
80907-3739
US

IV. Provider business mailing address

4419 CENTENNIAL #106
COLORADO SPRINGS CO
80907
US

V. Phone/Fax

Practice location:
  • Phone: 719-351-8286
  • Fax: 719-265-9334
Mailing address:
  • Phone: 719-351-8286
  • Fax: 719-265-9334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: