Healthcare Provider Details

I. General information

NPI: 1528136348
Provider Name (Legal Business Name): MARTHA DIANE HUBBARD R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 HWY 24 UNIT 2 C
DIVIDE CO
80814
US

IV. Provider business mailing address

1140 FOREST EDGE RD
WOODLAND PARK CO
80863-1238
US

V. Phone/Fax

Practice location:
  • Phone: 719-687-6416
  • Fax: 719-687-6501
Mailing address:
  • Phone: 719-687-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number94451
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: