Healthcare Provider Details

I. General information

NPI: 1194662007
Provider Name (Legal Business Name): ANGELIQUE BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 S PRAIRIE AVE
PUEBLO CO
81005-1724
US

IV. Provider business mailing address

536 S PRAIRIE AVE
PUEBLO CO
81005-1724
US

V. Phone/Fax

Practice location:
  • Phone: 719-334-5460
  • Fax:
Mailing address:
  • Phone: 719-334-5460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.1001921-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: