Healthcare Provider Details

I. General information

NPI: 1871322180
Provider Name (Legal Business Name): ELLEN JANE DISESA WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9780 PYRAMID CT STE 260
ENGLEWOOD CO
80112-7060
US

IV. Provider business mailing address

2240 N CLAY ST UNIT 404
DENVER CO
80211-5192
US

V. Phone/Fax

Practice location:
  • Phone: 720-420-1570
  • Fax: 866-657-9471
Mailing address:
  • Phone: 720-746-8533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPN.1000000-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: