Provider Demographics
NPI:1205203098
Name:PRANTL, NANCY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:PRANTL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5101
Mailing Address - Country:US
Mailing Address - Phone:719-344-7158
Mailing Address - Fax:719-344-7837
Practice Address - Street 1:410 GOLD PASS HTS
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3882
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-344-7817
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0991893-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15770052Medicaid
CO15770052Medicaid