Provider Demographics
NPI:1952552408
Name:ZAVALA, JULIE M (PNP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:ZAVALA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:M
Other - Last Name:WAHLSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:9197 GRANT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-4361
Mailing Address - Country:US
Mailing Address - Phone:303-869-2173
Mailing Address - Fax:303-962-1515
Practice Address - Street 1:9197 GRANT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4361
Practice Address - Country:US
Practice Address - Phone:303-869-2173
Practice Address - Fax:303-962-1515
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO123035363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO123035OtherSTATE LICENSE
CO13202847Medicaid