Provider Demographics
NPI:1851535033
Name:STANCZYK, KELLY JEAN (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:STANCZYK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:CLARKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:2318 COCKLEBUR LANE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:970-282-6975
Mailing Address - Fax:
Practice Address - Street 1:1107 SOUTH LEMAY AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3957
Practice Address - Country:US
Practice Address - Phone:970-493-7442
Practice Address - Fax:970-493-2990
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO304737Medicare PIN