Provider Demographics
NPI:1790940252
Name:SEGGELKE, STACEY (CNS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SEGGELKE
Suffix:
Gender:F
Credentials:CNS
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 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:303-493-7000
Mailing Address - Fax:
Practice Address - Street 1:12605 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2545
Practice Address - Country:US
Practice Address - Phone:720-848-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO115674364S00000X
COAPN.0005774-CNS364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82129240Medicaid
COCO301127Medicare PIN