Provider Demographics
NPI:1306881131
Name:FRICK, THERESA (CNM)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FRICK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:FRICK-CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4226
Mailing Address - Country:US
Mailing Address - Phone:970-252-2542
Mailing Address - Fax:970-252-2544
Practice Address - Street 1:900 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4226
Practice Address - Country:US
Practice Address - Phone:970-252-2542
Practice Address - Fax:970-252-2544
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN90448367A00000X
COAPN.0002151-CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07904485Medicaid