Provider Demographics
NPI:1568949402
Name:BORTZ, PENNY SUE (RN, CNOR, RNFA)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:SUE
Last Name:BORTZ
Suffix:
Gender:F
Credentials:RN, CNOR, RNFA
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 4159
Mailing Address - Street 2:
Mailing Address - City:GYPSUM
Mailing Address - State:CO
Mailing Address - Zip Code:81637-4159
Mailing Address - Country:US
Mailing Address - Phone:970-376-7240
Mailing Address - Fax:
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4259
Practice Address - Country:US
Practice Address - Phone:970-384-7430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0127210163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00-305-1220OtherDRIVERS LICENSE