MEDICARE: LUSH MEDICAL AESTHETICS

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

General Provider Information

NPI Number	:	1043105638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUSH MEDICAL AESTHETICS

Provider Business Mailing Address
First Line	:	7536 TELLURIDE DR
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-8921
Country	:	US
Telephone Number	:	406-560-0878
Fax Number	:

Provider Business Practice Location Address
First Line	:	307 W LINCOLNWAY
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-4437
Country	:	US
Telephone Number	:	307-630-4191
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATHERINE SANNE
Credential	:	APRN
Telephone Number	:	406-560-0878

Provider Enumeration Date	:	06/12/2025
Last Update Date	:	06/12/2025

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