Healthcare Provider Details

I. General information

NPI: 1700445467
Provider Name (Legal Business Name): LIBERTY ANGEL RUIZ AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COLORADO AVE
PUEBLO CO
81004-2006
US

IV. Provider business mailing address

2423 SNOW CAP CT
COLORADO SPRINGS CO
80915-1982
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-8711
  • Fax:
Mailing address:
  • Phone: 719-359-3913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN.0994697-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN.0994697-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: