Provider Demographics
NPI:1184751141
Name:ANNIBELLA, CAROL A
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:ANNIBELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4851 INDEPENDENCE ST
Mailing Address - Street 2:STE 270
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6715
Mailing Address - Country:US
Mailing Address - Phone:303-467-5717
Mailing Address - Fax:
Practice Address - Street 1:4851 INDEPENDENCE ST STE 270
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6712
Practice Address - Country:US
Practice Address - Phone:303-467-5717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3056363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50074580Medicaid
012025OtherKAISER-COMMERCIAL NUMBER
CO50074580Medicaid
COK11014Medicare ID - Type Unspecified
COCO304086Medicare PIN