Healthcare Provider Details

I. General information

NPI: 1396622676
Provider Name (Legal Business Name): ALISHA NETTIK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W 15TH ST STE 200
PUEBLO CO
81003-2716
US

IV. Provider business mailing address

525 W 15TH ST STE 200
PUEBLO CO
81003-2716
US

V. Phone/Fax

Practice location:
  • Phone: 719-296-6000
  • Fax: 719-296-6000
Mailing address:
  • Phone: 719-296-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN.0172211
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: