Healthcare Provider Details

I. General information

NPI: 1447646245
Provider Name (Legal Business Name): VIRGINIA PETICOLAS RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4856 INNOVATION DR STE B
FORT COLLINS CO
80525-5540
US

IV. Provider business mailing address

4856 INNOVATION DR STE B
FORT COLLINS CO
80525-5540
US

V. Phone/Fax

Practice location:
  • Phone: 970-494-4200
  • Fax: 970-377-0967
Mailing address:
  • Phone: 970-494-4200
  • Fax: 970-377-0967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1628230
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: