Healthcare Provider Details

I. General information

NPI: 1902934847
Provider Name (Legal Business Name): MARY LYNNE STILSON NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 N ACADEMY BLVD
COLORADO SPRINGS CO
80917-5101
US

IV. Provider business mailing address

2314 N CHELTON RD
COLORADO SPRINGS CO
80909-1306
US

V. Phone/Fax

Practice location:
  • Phone: 719-776-3443
  • Fax: 719-776-3149
Mailing address:
  • Phone: 719-596-2949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number94344
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: