Provider Demographics
NPI:1619193893
Name:KEPHART, TAMI LYNNE (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:TAMI
Middle Name:LYNNE
Last Name:KEPHART
Suffix:
Gender:F
Credentials:CPNP
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 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:303-493-7000
Mailing Address - Fax:
Practice Address - Street 1:4125 BRIARGATE BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3490
Practice Address - Country:US
Practice Address - Phone:719-305-9025
Practice Address - Fax:719-305-9026
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO110077363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07110075Medicaid
COCOA103160Medicare PIN