Provider Demographics
NPI:1790179448
Name:KILCULLEN, COLLEEN ANNE (NP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANNE
Last Name:KILCULLEN
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:PO BOX 9049
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-9049
Mailing Address - Country:US
Mailing Address - Phone:303-415-4155
Mailing Address - Fax:303-776-3109
Practice Address - Street 1:2101 KEN PRATT BLVD STE 104A
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6568
Practice Address - Country:US
Practice Address - Phone:303-415-4155
Practice Address - Fax:303-776-3109
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0091467363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97978353Medicaid
CO437076YMMWMedicare UPIN