=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710398573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACIE LYNN KIPP FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2014
-----------------------------------------------------
Last Update Date | 01/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | EVANS ARMY COMMUNITY HOSPITAL, 1650 CIR B7500
-----------------------------------------------------
City | FT CARSON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-524-4737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5480 SAMPLE WAY
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80919-2491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-338-8686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APN.0991051
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------