1902895683 NPI number — KELLY CARROLL FOWLER NP

Table of content: KELLY CARROLL FOWLER NP (NPI 1902895683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902895683 NPI number — KELLY CARROLL FOWLER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOWLER
Provider First Name:
KELLY
Provider Middle Name:
CARROLL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARROLL
Provider Other First Name:
KELLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902895683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1345 PLAZA COURT N.
Provider Second Line Business Mailing Address:
#1A
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80026-2832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-665-3036
Provider Business Mailing Address Fax Number:
303-604-6243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8990 N WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THORNTON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80229-4537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-929-1655
Provider Business Practice Location Address Fax Number:
303-604-6243
Provider Enumeration Date:
10/17/2005

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:  173308 , 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)

  • Identifier: 81480024 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".