Basic Information
| Provider Information | |||||||||
| NPI: | 1518590017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGLISA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2008 E JACKSON ST APT 10 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192178127 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6190 BARNES RD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809222600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192471511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2020 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CO | Y |
No ID Information.