Healthcare Provider Details

I. General information

NPI: 1972024453
Provider Name (Legal Business Name): ANGELA MARIE PERIDES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 01/09/2022
Certification Date: 01/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3676 PARKER BLVD
PUEBLO CO
81008-2212
US

IV. Provider business mailing address

49 WILD ROSE DR
CANON CITY CO
81212-9468
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-2200
  • Fax: 719-553-2216
Mailing address:
  • Phone: 719-371-4248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number106696
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0995502-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: