Provider Demographics
NPI:1245401835
Name:FARRELL, KATHLEEN T (RD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:T
Last Name:FARRELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MAPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3979
Mailing Address - Country:US
Mailing Address - Phone:303-544-5700
Mailing Address - Fax:303-544-5710
Practice Address - Street 1:311 MAPLETON AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3979
Practice Address - Country:US
Practice Address - Phone:303-544-5700
Practice Address - Fax:303-544-5710
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
518120133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO300127Medicare PIN
COCOA102450Medicare PIN