=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134249964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVENS FAMILY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 LATIGO LN SUITE C
-----------------------------------------------------
City | CANON CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81212-8112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-276-3211
-----------------------------------------------------
Fax | 719-276-3011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1304 CHINOOK LN
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81001-1851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-544-5622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTIONER
-----------------------------------------------------
Name | MS. PATRICIA LYNN HEAD
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 719-276-3211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 98310
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------