1114400256 NPI number — LESLIE MARIE KENNEDY NP-C

Table of content: LESLIE MARIE KENNEDY NP-C (NPI 1114400256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114400256 NPI number — LESLIE MARIE KENNEDY NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
LESLIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THEISEN
Provider Other First Name:
LESLIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1114400256
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1735 S PUBLIC RD STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80026-7093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-665-3036
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8510 BRYANT ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTMINSTER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80031-3845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-650-4460
Provider Business Practice Location Address Fax Number:
720-565-4130
Provider Enumeration Date:
09/14/2018

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: 363LF0000X , with the licence number:  4704347248 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 209018394 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APN0997082NP , 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)