Provider Demographics
NPI:1215394820
Name:MOON WELCH, INDIZO STAR (RN, PMHNP)
Entity Type:Individual
Prefix:MS
First Name:INDIZO
Middle Name:STAR
Last Name:MOON WELCH
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 N YORK ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-4658
Mailing Address - Country:US
Mailing Address - Phone:808-345-7393
Mailing Address - Fax:
Practice Address - Street 1:2831 N YORK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-4658
Practice Address - Country:US
Practice Address - Phone:808-345-7393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1627689163W00000X
COAPN.0997135363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse