Provider Demographics
NPI:1013720853
Name:AVILA, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 GRAND VISTA CIR APT 111
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-5247
Mailing Address - Country:US
Mailing Address - Phone:719-413-9275
Mailing Address - Fax:
Practice Address - Street 1:4150 E WOODMEN RD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-8042
Practice Address - Country:US
Practice Address - Phone:719-632-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.1000488-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily