Healthcare Provider Details

I. General information

NPI: 1396770871
Provider Name (Legal Business Name): CAROL FOX GOTHAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 COLLAND DR
FORT COLLINS CO
80525-4205
US

IV. Provider business mailing address

1627 E 18TH ST
LOVELAND CO
80538-4209
US

V. Phone/Fax

Practice location:
  • Phone: 970-461-8031
  • Fax: 970-461-8932
Mailing address:
  • Phone: 970-663-0135
  • Fax: 970-461-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number70182
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: