Provider Demographics
NPI:1841766268
Name:GRISSOM, AZURE (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:AZURE
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 E BOULDER ST STE 204
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5756
Mailing Address - Country:US
Mailing Address - Phone:719-471-1069
Mailing Address - Fax:195-774-8287
Practice Address - Street 1:1725 E BOULDER ST STE 204
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5756
Practice Address - Country:US
Practice Address - Phone:719-471-1069
Practice Address - Fax:195-774-8287
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0994256363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily