Healthcare Provider Details

I. General information

NPI: 1285363879
Provider Name (Legal Business Name): RENAISSANCE ZILLIOUX FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 28 1/4 RD
GRAND JUNCTION CO
81506-6019
US

IV. Provider business mailing address

PO BOX 1727
GRAND JUNCTION CO
81502-1727
US

V. Phone/Fax

Practice location:
  • Phone: 970-263-2600
  • Fax: 970-263-2692
Mailing address:
  • Phone: 970-263-2600
  • Fax: 970-263-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1651656
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: