Provider Demographics
NPI:1083269997
Name:GATES, ALISSA RENE (LPN)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:RENE
Last Name:GATES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:RENE
Other - Last Name:BRUMMUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5360 N ACADEMY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4006
Mailing Address - Country:US
Mailing Address - Phone:719-434-2061
Mailing Address - Fax:
Practice Address - Street 1:5360 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4006
Practice Address - Country:US
Practice Address - Phone:719-434-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0335459164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse