Individual
FOSSY NICOLE EVENSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
10699 MELODY DR STE 2, NORTHGLENN, CO 80234-4131
(303) 252-4179
Mailing address
1815 E 135TH AVE, THORNTON, CO 80241-1965
(303) 997-1242
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12-276-1010
DRIVERS LICENSE
CO
Enumeration date
01/11/2022
Last updated
01/11/2022
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