Provider Demographics
NPI:1356810550
Name:BAKER, ROY JACKSON (LPN)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:JACKSON
Last Name:BAKER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 N ACADEMY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4006
Mailing Address - Country:US
Mailing Address - Phone:719-434-2016
Mailing Address - Fax:719-434-2275
Practice Address - Street 1:521 ROWE LN
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-2624
Practice Address - Country:US
Practice Address - Phone:719-213-8531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0043255164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty