Healthcare Provider Details

I. General information

NPI: 1356781934
Provider Name (Legal Business Name): ELIZABETH LEE BRINK CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5028 GALLOPING GOOSE WAY
COLORADO SPRINGS CO
80924
US

IV. Provider business mailing address

5028 GALLOPING GOOSE WAY
COLORADO SPRINGS CO
80924-2915
US

V. Phone/Fax

Practice location:
  • Phone: 719-367-9405
  • Fax: 719-434-9777
Mailing address:
  • Phone: 719-367-9405
  • Fax: 719-434-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License NumberRN60502401
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberAPN.0993812-CNM
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP60696895
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAPN.0993812-CNM
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: