Healthcare Provider Details

I. General information

NPI: 1831258367
Provider Name (Legal Business Name): LEE MICHAEL FONSECA NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 OUTLOOK BLVD SUITE 37
PUEBLO CO
81008-1667
US

IV. Provider business mailing address

PO BOX 800022 SUITE 37
KANSAS CITY MO
64180-0022
US

V. Phone/Fax

Practice location:
  • Phone: 719-562-6254
  • Fax: 719-562-6255
Mailing address:
  • Phone: 800-953-0103
  • Fax: 303-765-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0004081-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number105831
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: