MEDICARE: LISA NICOLE HEINECKE RN, LMT

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	225700000X	Massage Therapist	MT.0022615	CO
2	163W00000X	Registered Nurse	1626334	CO

General Provider Information

NPI Number	:	1861198509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA NICOLE HEINECKE RN, LMT

Provider Business Mailing Address
First Line	:	2117 W KIOWA ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-3445
Country	:	US
Telephone Number	:	719-257-3177
Fax Number	:

Provider Business Practice Location Address
First Line	:	2524 W COLORADO AVE STE 205
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-6016
Country	:	US
Telephone Number	:	719-257-3177
Fax Number	:

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

Provider Enumeration Date	:	02/03/2023
Last Update Date	:	11/09/2024

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