Lori Ptak
Individual provider Active NPI Registered Nurse · Divide, CO
NPI 1508372152 · NPPES record last updated Mar 17, 2018
Key facts
- NPI
- 1508372152
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Registered Nurse 163W00000X
- License
- RN.1641286 (CO)
- Practice address
- 11115 W Highway 24
Unit 2C
Divide, CO 80814 - Phone
- (719) 687-6416
- Fax
- (719) 687-6501
- NPI assigned
- Dec 19, 2017
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RN.1641286 | CO | MD | Registered Nurse |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Teller County | Past | Accepting new patients | |
| Teller County Public Health | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | RN.1641286 | CO | Yes |
Addresses
Primary practice location
11115 W Highway 24
Unit 2C
Divide, CO 80814
Mailing address
11115 W. Highway 24
Unit 2C
Divide, CO 80814
Phone (719) 687-6416
Other practice location 1
166 E Bennett Ave
Cripple Creek, CO 80813
Phone (719) 648-9760
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 04540548 | Medicaid | CO |
Other providers in Divide, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 17, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.