Healthcare Provider Details

I. General information

NPI: 1639806912
Provider Name (Legal Business Name): AUDREY L GENTILE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUDREY L. ANDERSON NP

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 S PRAIRIE AVE
PUEBLO CO
81005-2886
US

IV. Provider business mailing address

2429 S PRAIRIE AVE
PUEBLO CO
81005-2886
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-5070
  • Fax: 719-896-2874
Mailing address:
  • Phone: 719-564-5070
  • Fax: 719-896-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN.0997843.NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0997843.NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: