Provider Demographics
NPI:1801884747
Name:WILTERDINK, MARY E (CNM)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:WILTERDINK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:303-788-8808
Mailing Address - Fax:303-788-6656
Practice Address - Street 1:701 E HAMPDEN AVE STE 110
Practice Address - Street 2:#465
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2736
Practice Address - Country:US
Practice Address - Phone:303-788-8808
Practice Address - Fax:303-788-6656
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1784367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07962236Medicaid
NM93026781Medicaid
COC810208Medicare PIN
CO448788Medicare PIN
CO07962236Medicaid