Healthcare Provider Details

I. General information

NPI: 1083412472
Provider Name (Legal Business Name): ROBERTA MARIE THORNTON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1591 TAOS RD BLDG A
PUEBLO CO
81006-1232
US

IV. Provider business mailing address

41 MONTEBELLO RD STE 204
PUEBLO CO
81001-1379
US

V. Phone/Fax

Practice location:
  • Phone: 719-423-1500
  • Fax:
Mailing address:
  • Phone: 719-545-2746
  • Fax: 719-545-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.1000617-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: