=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780719633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA M HENN CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 02/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 E BOULDER ST STE 104
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-365-5888
-----------------------------------------------------
Fax | 719-365-6905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17365 CARIBOU DR E
-----------------------------------------------------
City | MONUMENT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80132-7410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-481-8529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 97933
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------