Healthcare Provider Details

I. General information

NPI: 1093174930
Provider Name (Legal Business Name): ALESSANDRA MARIE BULLIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 N C ST
CRIPPLE CREEK CO
80813
US

IV. Provider business mailing address

5799 STETSON HILLS BLVD
COLORADO SPRINGS CO
80917-4223
US

V. Phone/Fax

Practice location:
  • Phone: 719-776-4310
  • Fax: 719-776-4320
Mailing address:
  • Phone: 719-471-2273
  • Fax: 719-380-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number992190
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0177189
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: