Healthcare Provider Details

I. General information

NPI: 1003650235
Provider Name (Legal Business Name): GINA MARIE CORSENTINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2024
Last Update Date: 06/22/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3732 FAIRFIELD LN
PUEBLO CO
81005-3251
US

IV. Provider business mailing address

3732 FAIRFIELD LN
PUEBLO CO
81005-3251
US

V. Phone/Fax

Practice location:
  • Phone: 719-671-8306
  • Fax:
Mailing address:
  • Phone: 719-671-8306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number885
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: