Provider Demographics
NPI:1619011418
Name:CALLANAN, KATHLEEN M
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:CALLANAN
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 1:504 HAPGOOD ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6966
Mailing Address - Country:US
Mailing Address - Phone:303-449-7298
Mailing Address - Fax:
Practice Address - Street 1:580 MOHAWK DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-3712
Practice Address - Country:US
Practice Address - Phone:303-239-7294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48406363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
005669OtherKAISER-COMMERCIAL NUMBER
CO89733711Medicaid
CO89733711Medicaid
COCK10904Medicare PIN