Healthcare Provider Details

I. General information

NPI: 1730216771
Provider Name (Legal Business Name): VIRGINIA C GILLISPIE ND, CNS, ACHPN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 N. GRAND AVE. STE 402
PUEBLO CO
81003-2658
US

IV. Provider business mailing address

PO BOX 560825
DENVER CO
80256-0825
US

V. Phone/Fax

Practice location:
  • Phone: 719-595-7760
  • Fax: 719-595-7765
Mailing address:
  • Phone: 719-595-7580
  • Fax: 719-545-0176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number112546
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number3310
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number991091
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: