Provider Demographics
NPI:1730216771
Name:GILLISPIE, VIRGINIA C (ND, CNS, ACHPN, CCM)
Entity type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:C
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:ND, CNS, ACHPN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:719-545-0176
Practice Address - Street 1:1619 N. GRAND AVE.
Practice Address - Street 2:STE 402
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2658
Practice Address - Country:US
Practice Address - Phone:719-595-7760
Practice Address - Fax:719-595-7765
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO112546163W00000X
CO3310364S00000X
CO991091363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
015038OtherKAISER-COMMERCIAL NUMBER
CO98552376Medicaid
015038OtherKAISER-COMMERCIAL NUMBER
CO98552376Medicaid