Provider Demographics
NPI:1316216898
Name:VANICA, NICOLE M (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:VANICA
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 150
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:CO
Mailing Address - Zip Code:81047-0150
Mailing Address - Country:US
Mailing Address - Phone:719-537-0712
Mailing Address - Fax:719-537-6284
Practice Address - Street 1:11600 W 2ND PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1527
Practice Address - Country:US
Practice Address - Phone:720-321-1048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO202862367500000X
MT175866367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOAAA3536Medicare PIN