Healthcare Provider Details

I. General information

NPI: 1114148483
Provider Name (Legal Business Name): NANCY J WILSTED RNC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W COLORADO AVENUE SUITE 206-B
COLORADO SPRINGS CO
80904-3863
US

IV. Provider business mailing address

2020 W COLORADO AVENUE SUITE 206-B
COLORADO SPRINGS CO
80904-3863
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-9969
  • Fax: 719-632-3654
Mailing address:
  • Phone: 719-632-9969
  • Fax: 719-632-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number48654
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: