MEDICARE: MARY AVILA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APN.1000488-NP	CO

General Provider Information

NPI Number	:	1013720853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY AVILA NP

Provider Business Mailing Address
First Line	:	2610 GRAND VISTA CIR APT 111
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-5247
Country	:	US
Telephone Number	:	719-413-9275
Fax Number	:

Provider Business Practice Location Address
First Line	:	4150 E WOODMEN RD STE 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-8042
Country	:	US
Telephone Number	:	719-632-4455
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	01/27/2025

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