Provider Demographics
NPI:1477516045
Name:NICKELL, REBECCA J (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:NICKELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:J
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:13402 W COAL MINE AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-5407
Mailing Address - Country:US
Mailing Address - Phone:303-730-2167
Mailing Address - Fax:303-996-4820
Practice Address - Street 1:206 W COUNTY LINE RD STE 300
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129
Practice Address - Country:US
Practice Address - Phone:303-795-5980
Practice Address - Fax:303-795-7881
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO020422OtherKAISER COMMERCIAL NUMBER
CO9000144571Medicaid
CO403385YU8DOtherGROUP MEMBER PTAN
CO403385YU8DOtherGROUP MEMBER PTAN
COI41446Medicare UPIN