Provider Demographics
NPI:1134249964
Name:HAVENS FAMILY CLINIC
Entity type:Organization
Organization Name:HAVENS FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:719-276-3211
Mailing Address - Street 1:1304 CHINOOK LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1851
Mailing Address - Country:US
Mailing Address - Phone:719-544-5622
Mailing Address - Fax:
Practice Address - Street 1:109 LATIGO LN
Practice Address - Street 2:SUITE C
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-8112
Practice Address - Country:US
Practice Address - Phone:719-276-3211
Practice Address - Fax:719-276-3011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO98310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COQ44509Medicare UPIN