Healthcare Provider Details

I. General information

NPI: 1215328570
Provider Name (Legal Business Name): JESSICA RUTH WALKUP CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA RUTH WALKUP SHENKMAN

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 09/21/2023
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR # B7500
FORT CARSON CO
80913-4613
US

IV. Provider business mailing address

1650 COCHRANE CIR # B7500
FORT CARSON CO
80913-4613
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7192
  • Fax:
Mailing address:
  • Phone: 719-526-7192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAC0001478
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number24172347
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: