Provider Demographics
NPI:1497730485
Name:KOLASSA, DARCY A (NPC)
Entity Type:Individual
Prefix:
First Name:DARCY
Middle Name:A
Last Name:KOLASSA
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:DARCY
Other - Middle Name:A
Other - Last Name:RUNDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2002 LELARAY ST
Mailing Address - Street 2:#100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2804
Mailing Address - Country:US
Mailing Address - Phone:719-632-7641
Mailing Address - Fax:719-632-2925
Practice Address - Street 1:2002 LELARAY ST
Practice Address - Street 2:#100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2804
Practice Address - Country:US
Practice Address - Phone:719-632-7641
Practice Address - Fax:719-632-2925
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO124262363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46334866Medicaid
803219Medicare ID - Type Unspecified
CO46334866Medicaid