Healthcare Provider Details

I. General information

NPI: 1215394820
Provider Name (Legal Business Name): INDIZO STAR MOON RN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: INDIZO STAR MOON WELCH RN, PMHNP-BC

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 WELTON ST
DENVER CO
80205-3020
US

IV. Provider business mailing address

2831 N YORK ST
DENVER CO
80205-4658
US

V. Phone/Fax

Practice location:
  • Phone: 720-443-3859
  • Fax: 983-203-9599
Mailing address:
  • Phone: 808-345-7393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0997135-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1627689
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: