Provider Demographics
NPI:1053642728
Name:MYATT, KATHY L (RN, MSN, PMHNP, BC)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:L
Last Name:MYATT
Suffix:
Gender:F
Credentials:RN, MSN, PMHNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 SOUTHPOINTE CT STE 104
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3800
Mailing Address - Country:US
Mailing Address - Phone:719-289-3173
Mailing Address - Fax:
Practice Address - Street 1:630 SOUTHPOINTE CT STE 104
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-289-3173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0000598-C-NP363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO579748YV8Medicaid
NC6113087Medicaid