Healthcare Provider Details

I. General information

NPI: 1689137952
Provider Name (Legal Business Name): MEAGAN LEIGH HASTIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 24TH ST
PUEBLO CO
81003-1499
US

IV. Provider business mailing address

PO BOX 846
GREEN MOUNTAIN FALLS CO
80819-0846
US

V. Phone/Fax

Practice location:
  • Phone: 719-650-5651
  • Fax:
Mailing address:
  • Phone: 719-650-5651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0997324-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.0204928
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: