Basic Information
| Provider Information | |||||||||
| NPI: | 1457671570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE | ||||||||
| Address2: | STE 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195382900 | ||||||||
| FaxNumber: | 7195382987 | ||||||||
| Practice Location | |||||||||
| Address1: | 5115 FONTAINE BLVD | ||||||||
| Address2: | 1 ST FLOOR | ||||||||
| City: | FOUNTAIN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808171061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193922000 | ||||||||
| FaxNumber: | 7193926937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 09/10/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN.0010189-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 95633847 | 05 | CO | MEDICAID | APN.0010189-NP | 01 | CO | MEDICAL LICENSE | OTHER |