Provider Demographics
NPI:1215210471
Name:BANASZAK, AMY M (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:M
Last Name:BANASZAK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 E FONTANERO ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907
Mailing Address - Country:US
Mailing Address - Phone:719-636-3829
Mailing Address - Fax:719-633-8571
Practice Address - Street 1:325 E FONTANERO ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:719-636-3829
Practice Address - Fax:719-633-8571
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP-990213363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16922778Medicaid
COCOAAAY377Medicare PIN