Healthcare Provider Details

I. General information

NPI: 1578545513
Provider Name (Legal Business Name): MICHAEL EUGENE LAFAYETTE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 HOLLOW BROOK DR STE 10
COLORADO SPRINGS CO
80918-1463
US

IV. Provider business mailing address

2165 HOLLOW BROOK DR STE 10
COLORADO SPRINGS CO
80918-1463
US

V. Phone/Fax

Practice location:
  • Phone: 719-434-3636
  • Fax: 719-434-3639
Mailing address:
  • Phone: 719-434-3636
  • Fax: 719-434-3639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71205
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: