Basic Information
| Provider Information | |||||||||
| NPI: | 1689641318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUSSBAUMER | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802062761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033884461 | ||||||||
| FaxNumber: | 3033981211 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802062761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033884461 | ||||||||
| FaxNumber: | 3032702206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4391 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363LF0000X | 4391 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 33236038 | 05 | CO | MEDICAID |