Provider Demographics
NPI:1154386365
Name:CHUCH, NANCY S (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:S
Last Name:CHUCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:S
Other - Last Name:KETTELKAMP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1600 N GRAND AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2700
Mailing Address - Country:US
Mailing Address - Phone:719-542-0072
Mailing Address - Fax:719-542-9888
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:STE 310
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2700
Practice Address - Country:US
Practice Address - Phone:719-542-0072
Practice Address - Fax:719-542-9888
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E25453Medicare UPIN