Provider Demographics
NPI:1871124248
Name:FLORISSANT FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:FLORISSANT FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C
Authorized Official - Phone:719-839-1923
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:CO
Mailing Address - Zip Code:80816-0189
Mailing Address - Country:US
Mailing Address - Phone:719-839-1923
Mailing Address - Fax:833-539-1731
Practice Address - Street 1:18100 COUNTY RD 1
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:CO
Practice Address - Zip Code:80816-9404
Practice Address - Country:US
Practice Address - Phone:719-839-1923
Practice Address - Fax:833-539-1731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-03
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care