Healthcare Provider Details

I. General information

NPI: 1528730918
Provider Name (Legal Business Name): MARIAH M SOUDER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1263 LAKE PLAZA DR STE 230
COLORADO SPRINGS CO
80906-3512
US

IV. Provider business mailing address

6285 GAMBLER PL
COLORADO SPRINGS CO
80908-1155
US

V. Phone/Fax

Practice location:
  • Phone: 719-776-3300
  • Fax: 719-776-3329
Mailing address:
  • Phone: 303-829-6208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0997121-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPN.0997121-NP
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN.0997121-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: