Healthcare Provider Details

I. General information

NPI: 1053991133
Provider Name (Legal Business Name): PEATA SETU-MALALA RN, NCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 COCHRANE CIR BLDG 7494
COLORADO SPRINGS CO
80913-4603
US

IV. Provider business mailing address

1665 COCHRANE CIR BLDG 7664
COLORADO SPRINGS CO
80913-4603
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-2629
  • Fax:
Mailing address:
  • Phone: 502-262-3196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number1102082
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: