1619029170 NPI number — MELISSA ANN BORTNEM

Table of content: MELISSA ANN BORTNEM (NPI 1619029170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619029170 NPI number — MELISSA ANN BORTNEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORTNEM
Provider First Name:
MELISSA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'DONNELL
Provider Other First Name:
MELISSA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619029170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8237 HARLAN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARVADA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80003-1725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-435-3120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5554 S PRINCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLETON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80120-1149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-730-8858
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CSW.09924616 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)