Provider Demographics
NPI:1366786261
Name:COLOVOS, STACI (ACNP)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:COLOVOS
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 WEST PRATT BLVD
Mailing Address - Street 2:#304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645
Mailing Address - Country:US
Mailing Address - Phone:773-447-8819
Mailing Address - Fax:
Practice Address - Street 1:4401 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-627-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6527571-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care