Healthcare Provider Details

I. General information

NPI: 1841077617
Provider Name (Legal Business Name): LAUREN BAROUSSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 16TH ST
PUEBLO CO
81003-2781
US

IV. Provider business mailing address

58 CLUB MANOR DR
PUEBLO CO
81008-1601
US

V. Phone/Fax

Practice location:
  • Phone: 719-584-4000
  • Fax:
Mailing address:
  • Phone: 719-584-4045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.0999109
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: