Healthcare Provider Details

I. General information

NPI: 1811591852
Provider Name (Legal Business Name): MARCELLA ANTOINETTE MASTERSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARCELLA NAVARRO FNP-BC

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 03/23/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 FORTINO BLVD STE D
PUEBLO CO
81008-2076
US

IV. Provider business mailing address

1310 FORTINO BLVD STE D
PUEBLO CO
81008-2076
US

V. Phone/Fax

Practice location:
  • Phone: 719-582-1898
  • Fax:
Mailing address:
  • Phone: 719-582-1898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN.1640139
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0996394-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: