Provider Demographics
NPI:1477011864
Name:DICKARD, KENNA
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:
Last Name:DICKARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 TANTRA DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6187
Mailing Address - Country:US
Mailing Address - Phone:540-656-0707
Mailing Address - Fax:
Practice Address - Street 1:1000 ALPINE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3406
Practice Address - Country:US
Practice Address - Phone:540-656-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator