Provider Demographics
NPI:1598319642
Name:BACH, CODY LEE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:LEE
Last Name:BACH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 W 118TH PL STE 5510
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-5041
Mailing Address - Country:US
Mailing Address - Phone:720-951-2072
Mailing Address - Fax:
Practice Address - Street 1:12167 SHERIDAN BLVD
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2417
Practice Address - Country:US
Practice Address - Phone:303-658-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0994785363LF0000X
MT177199363L00000X
UT11398024-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1598319642Medicaid