Provider Demographics
NPI:1710984307
Name:KIPE, JACKI L (CRNA)
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:L
Last Name:KIPE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2828
Mailing Address - Country:US
Mailing Address - Phone:719-543-7827
Mailing Address - Fax:719-543-7882
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-543-7877
Practice Address - Fax:719-543-7882
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO170699367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
U41491Medicare UPIN
801621Medicare ID - Type Unspecified