Provider Demographics
NPI:1659928562
Name:NANCE, TINA M (NP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:NANCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 FLINTRIDGE DR STE 220O
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4273
Mailing Address - Country:US
Mailing Address - Phone:719-407-3312
Mailing Address - Fax:
Practice Address - Street 1:4740 FLINTRIDGE DR STE 220O
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4273
Practice Address - Country:US
Practice Address - Phone:719-407-3312
Practice Address - Fax:719-284-7041
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN1634461163W00000X
COAPN.0995055-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000176721Medicaid