Healthcare Provider Details

I. General information

NPI: 1376831958
Provider Name (Legal Business Name): DR. STACEY PICCONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 S CASCADE AVE STE 140
COLORADO SPRINGS CO
80903-1624
US

IV. Provider business mailing address

1625 MEDICAL CENTER PT STE 210
COLORADO SPRINGS CO
80907-5798
US

V. Phone/Fax

Practice location:
  • Phone: 719-538-2900
  • Fax: 719-538-2987
Mailing address:
  • Phone: 719-635-5148
  • Fax: 719-448-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberLD60230650
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD.0000764
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: