Provider Demographics
NPI:1427159664
Name:DOUGLAS, LANNY (APRN)
Entity type:Individual
Prefix:MR
First Name:LANNY
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271144
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80527-1144
Mailing Address - Country:US
Mailing Address - Phone:970-556-4502
Mailing Address - Fax:970-493-5131
Practice Address - Street 1:400 EAST HORSETOOTH RD
Practice Address - Street 2:SUITE 307
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-556-4502
Practice Address - Fax:970-493-5131
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY18756.196364SP0807X
CO180365-5256364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW308674Medicare ID - Type Unspecified
WYS54469Medicare UPIN