Healthcare Provider Details

I. General information

NPI: 1215210471
Provider Name (Legal Business Name): AMY M BANASZAK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS AMY M JOHNSON

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E FONTANERO ST
COLORADO SPRINGS CO
80907
US

IV. Provider business mailing address

325 E FONTANERO ST
COLORADO SPRINGS CO
80907
US

V. Phone/Fax

Practice location:
  • Phone: 719-636-3829
  • Fax: 719-633-8571
Mailing address:
  • Phone: 719-636-3829
  • Fax: 719-633-8571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-990213
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: