1730412958 NPI number — MRS. NICOLE DYAN KENNEDY PA

Table of content: MRS. NICOLE DYAN KENNEDY PA (NPI 1730412958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730412958 NPI number — MRS. NICOLE DYAN KENNEDY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
NICOLE
Provider Middle Name:
DYAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACOBS
Provider Other First Name:
NICOLE
Provider Other Middle Name:
DYAN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730412958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 EAST HARVARD AVENUE
Provider Second Line Business Mailing Address:
SUITE 285
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-777-3333
Provider Business Mailing Address Fax Number:
303-733-4441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 EAST HARVARD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 285
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-777-3333
Provider Business Practice Location Address Fax Number:
303-733-4441
Provider Enumeration Date:
09/08/2009

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: 363A00000X , with the licence number:  2841 , 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)