Provider Demographics
NPI:1487641122
Name:FRALICK, KELLY (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FRALICK
Suffix:
Gender:F
Credentials:NP
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 848997
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8997
Mailing Address - Country:US
Mailing Address - Phone:970-476-1110
Mailing Address - Fax:
Practice Address - Street 1:108 S FRONTAGE ROAD WEST
Practice Address - Street 2:SUITE 206
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657
Practice Address - Country:US
Practice Address - Phone:970-476-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO107264363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
COS72933Medicare UPIN
CO518628Medicare ID - Type Unspecified
COCO301663Medicare PIN