MEDICARE: NANCY J WILSTED RNC 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	363LW0102X	Women's Health Nurse Practitioner	48654	CO

General Provider Information

NPI Number	:	1114148483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY J WILSTED RNC NP

Provider Business Mailing Address
First Line	:	2020 W COLORADO AVENUE
Second Line	:	SUITE 206-B
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-3863
Country	:	US
Telephone Number	:	719-632-9969
Fax Number	:	719-632-3654

Provider Business Practice Location Address
First Line	:	2020 W COLORADO AVENUE
Second Line	:	SUITE 206-B
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-3863
Country	:	US
Telephone Number	:	719-632-9969
Fax Number	:	719-632-3654

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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