Healthcare Provider Details

I. General information

NPI: 1720385016
Provider Name (Legal Business Name): ROCKY MOUNTAIN PRIMARY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 S MAIN ST SUITE 101
PUEBLO CO
81003-3415
US

IV. Provider business mailing address

131 S MAIN ST SUITE 101
PUEBLO CO
81003-3415
US

V. Phone/Fax

Practice location:
  • Phone: 719-924-9398
  • Fax: 719-924-9593
Mailing address:
  • Phone: 719-924-9398
  • Fax: 719-924-9593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number65214
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateCO

VIII. Authorized Official

Name: MRS. ASHLEY N. KIRBY
Title or Position: NURSE PRACTITIONER/OWNER
Credential: FNP-C
Phone: 719-924-9398