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General NPI Number Information
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NPI Number | 1578214672
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Entity Type | Individual
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Provider Name | FOSSY NICOLE EVENSON
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Gender | Female
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Dates
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Enumeration Date | 01/11/2022
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Last Update Date | 01/11/2022
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Provider Practice Location Address
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Address Line | 10699 MELODY DR STE 2
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City | NORTHGLENN
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State | CO
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Zip | 80234-4131
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Country | US
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Telephone | 303-252-4179
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Fax |
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Provider Business Mailing Address
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Address Line | 1815 E 135TH AVE
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City | THORNTON
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State | CO
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Zip | 80241-1965
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Country | US
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Telephone | 303-997-1242
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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