Healthcare Provider Details

I. General information

NPI: 1265249973
Provider Name (Legal Business Name): SHELLY JOLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 03/12/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3260 E WOODMEN RD STE 210
COLORADO SPRINGS CO
80920-3587
US

IV. Provider business mailing address

4450 SETON PL
COLORADO SPRINGS CO
80918-5209
US

V. Phone/Fax

Practice location:
  • Phone: 719-262-0852
  • Fax: 719-262-0853
Mailing address:
  • Phone: 719-205-9985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF12240290
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number40494
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: