Healthcare Provider Details

I. General information

NPI: 1538330113
Provider Name (Legal Business Name): CAROL A GANNON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 W 20TH ST UNIT 101
GREELEY CO
80634-9640
US

IV. Provider business mailing address

6801 W 20TH ST UNIT 101
GREELEY CO
80634-9640
US

V. Phone/Fax

Practice location:
  • Phone: 970-378-8000
  • Fax: 970-378-8088
Mailing address:
  • Phone: 970-378-8000
  • Fax: 970-378-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN.0116733
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRXN.0099175-NP
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0002761-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: