Provider Demographics
NPI:1750461521
Name:VAN DYKE, KRISTINE ANNE (NP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ANNE
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 S OSWEGO COURT
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-3112
Mailing Address - Country:US
Mailing Address - Phone:303-745-3864
Mailing Address - Fax:
Practice Address - Street 1:290 S MONACO PKWY
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224
Practice Address - Country:US
Practice Address - Phone:303-355-2525
Practice Address - Fax:303-333-6960
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO52014363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00259565OtherRR MEDICARE
COP00259565OtherRR MEDICARE
S21419Medicare UPIN