Provider Demographics
NPI:1467225730
Name:COLORADO STATE UNIVERSITY PUEBLO
Entity Type:Organization
Organization Name:COLORADO STATE UNIVERSITY PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DEAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:719-549-2830
Mailing Address - Street 1:2200 BONFORTE BLVD # 172
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-4901
Mailing Address - Country:US
Mailing Address - Phone:719-549-2830
Mailing Address - Fax:719-549-2646
Practice Address - Street 1:2200 BONFORTE BLVD # 172
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-4901
Practice Address - Country:US
Practice Address - Phone:719-549-2830
Practice Address - Fax:719-549-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty