Provider Demographics
NPI:1811214877
Name:WIECHERT, KELLY (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WIECHERT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80523-0001
Mailing Address - Country:US
Mailing Address - Phone:970-491-7121
Mailing Address - Fax:
Practice Address - Street 1:600 SOUTH DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523-0001
Practice Address - Country:US
Practice Address - Phone:970-491-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO175410163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse