MEDICARE: AZURE GRISSOM APRN, FNP-C

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	0994256	CO

General Provider Information

NPI Number	:	1841766268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AZURE GRISSOM APRN, FNP-C

Provider Business Mailing Address
First Line	:	1725 E BOULDER ST STE 204
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5756
Country	:	US
Telephone Number	:	719-471-1069
Fax Number	:	195-774-8287

Provider Business Practice Location Address
First Line	:	1725 E BOULDER ST STE 204
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5756
Country	:	US
Telephone Number	:	719-471-1069
Fax Number	:	195-774-8287

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

Provider Enumeration Date	:	10/24/2018
Last Update Date	:	02/28/2022

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