Provider Demographics
NPI:1013667880
Name:DEVINE ARCH, KELLY JEAN (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:DEVINE ARCH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:DEVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1130 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2453
Mailing Address - Country:US
Mailing Address - Phone:970-581-3591
Mailing Address - Fax:
Practice Address - Street 1:1950 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3129
Practice Address - Country:US
Practice Address - Phone:303-315-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099743367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife