Provider Demographics
NPI:1710258579
Name:REBERRY, KELLEY L (PAC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:L
Last Name:REBERRY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:125 RAMPART WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-6429
Mailing Address - Country:US
Mailing Address - Phone:720-858-7600
Mailing Address - Fax:720-858-7610
Practice Address - Street 1:125 RAMPART WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-6429
Practice Address - Country:US
Practice Address - Phone:720-858-7600
Practice Address - Fax:720-858-7610
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2111363A00000X
CO3760363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant