Provider Demographics
NPI:1629688718
Name:RETHERFORD, KRISHA ANNE
Entity Type:Individual
Prefix:
First Name:KRISHA
Middle Name:ANNE
Last Name:RETHERFORD
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 1:25 CROSSROADS DR STE 306
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5437
Mailing Address - Country:US
Mailing Address - Phone:866-953-3111
Mailing Address - Fax:
Practice Address - Street 1:255 S ROUTT ST STE 420
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2271
Practice Address - Country:US
Practice Address - Phone:303-985-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COPA.0006663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program