Provider Demographics
NPI:1811591852
Name:MASTERSON, MARCELLA ANTOINETTE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARCELLA
Middle Name:ANTOINETTE
Last Name:MASTERSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:
Other - Last Name:NAVARRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1310 FORTINO BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2076
Mailing Address - Country:US
Mailing Address - Phone:719-582-1898
Mailing Address - Fax:
Practice Address - Street 1:1310 FORTINO BLVD STE D
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2076
Practice Address - Country:US
Practice Address - Phone:719-582-1898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1640139163WE0003X
COAPN.0996394-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency