Healthcare Provider Details

I. General information

NPI: 1891178182
Provider Name (Legal Business Name): ANNIE MICHELE FAGUNDES NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2015
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST SPC BASE
COLORADO SPRINGS CO
80914-1541
US

IV. Provider business mailing address

559 VINCENT ST SPC BASE
COLORADO SPRINGS CO
80914-1541
US

V. Phone/Fax

Practice location:
  • Phone: 719-556-2322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: