Basic Information
| Provider Information | |||||||||
| NPI: | 1013085968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVER | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438718 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 E ROUTT | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 87612 | CO | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 61573744 | 05 | CO | MEDICAID |