Provider Demographics
NPI:1598206435
Name:HENECKE, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:HENECKE
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 1:824 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-4738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:824 ELM ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-4738
Practice Address - Country:US
Practice Address - Phone:970-218-2452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-11
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1617943163W00000X
COAPN.0992990-NP363LP0808X
CORXN.0102515-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse