Healthcare Provider Details

I. General information

NPI: 1457553992
Provider Name (Legal Business Name): AMANDA GAIL HEINRICHS TYACKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 HALE PKWY SUITE 400
DENVER CO
80220-4020
US

IV. Provider business mailing address

5433 S VERSAILLES ST
AURORA CO
80015-6526
US

V. Phone/Fax

Practice location:
  • Phone: 303-280-0900
  • Fax: 303-280-3858
Mailing address:
  • Phone: 720-876-1171
  • Fax: 303-280-3858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number111324
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: