Provider Demographics
NPI:1174682124
Name:PRINCE, KELLEY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:81423-0280
Mailing Address - Country:US
Mailing Address - Phone:970-327-4233
Mailing Address - Fax:970-327-4228
Practice Address - Street 1:1350 S ASPEN ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:CO
Practice Address - Zip Code:81423
Practice Address - Country:US
Practice Address - Phone:970-327-4233
Practice Address - Fax:970-327-4228
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240604207Q00000X
CODR.0066881207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174682124Medicaid
CAAV254ZMedicare PIN
CA1174682124Medicaid