Healthcare Provider Details

I. General information

NPI: 1043885205
Provider Name (Legal Business Name): VERANIQUE NODINE REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 W HWY 24, UNIT 2C
DIVIDE CO
80814
US

IV. Provider business mailing address

P.O. BOX 928 11115 W. HWY. 24, UNIT 2C
DIVIDE CO
80814
US

V. Phone/Fax

Practice location:
  • Phone: 719-687-6416
  • Fax:
Mailing address:
  • Phone: 719-687-6416
  • Fax: 719-687-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number28154699A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: