Provider Demographics
NPI:1043749195
Name:COLPITTS, KENNETH WESLEY (RN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WESLEY
Last Name:COLPITTS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7805 W CANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1736
Mailing Address - Country:US
Mailing Address - Phone:928-606-5179
Mailing Address - Fax:
Practice Address - Street 1:5610 W GAGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1349
Practice Address - Country:US
Practice Address - Phone:928-606-5179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-11
Last Update Date:2017-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID46583163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse