Provider Demographics
NPI:1033146329
Name:AGNOLETTO, SALLY (CRNA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:AGNOLETTO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2994
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2994
Mailing Address - Country:US
Mailing Address - Phone:303-422-9438
Mailing Address - Fax:303-422-9474
Practice Address - Street 1:181 W MEADOW DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5242
Practice Address - Country:US
Practice Address - Phone:303-422-9438
Practice Address - Fax:303-422-9474
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCRA-510367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17084580Medicaid
COC543018Medicare PIN
COCOA101996Medicare PIN