Provider Demographics
NPI:1760844328
Name:NEWSOM, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NEWSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10434 BLUEGRASS ST
Mailing Address - Street 2:
Mailing Address - City:FIRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:80504-4516
Mailing Address - Country:US
Mailing Address - Phone:720-256-5191
Mailing Address - Fax:
Practice Address - Street 1:10434 BLUEGRASS ST
Practice Address - Street 2:
Practice Address - City:FIRESTONE
Practice Address - State:CO
Practice Address - Zip Code:80504-4516
Practice Address - Country:US
Practice Address - Phone:720-256-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services