Basic Information
Provider Information | |||||||||
NPI: | 1003936121 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAILEY | ||||||||
FirstName: | KERI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 720 S COLORADO BLVD | ||||||||
Address2: | SUITE 220A | ||||||||
City: | GLENDALE | ||||||||
State: | CO | ||||||||
PostalCode: | 802461912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3035848000 | ||||||||
FaxNumber: | 8662100907 | ||||||||
Practice Location | |||||||||
Address1: | 1601 E 19TH AVE | ||||||||
Address2: | SUITE 5500 | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802181291 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3038396001 | ||||||||
FaxNumber: | 3038396033 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2007 | ||||||||
LastUpdateDate: | 05/16/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 161119 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 04901363 | 01 | CO | MEDICAID PRACTICE NUMBER | OTHER | 15380840 | 05 | CO |   | MEDICAID | 37402552 | 01 | CO | MEDICAID PRACTICE NUMBER | OTHER | 54552826 | 01 | CO | MEDICAID PRACTICE NUMBER | OTHER | C809609 | 01 | CO | MEDICARE GROUP NUMBER | OTHER | 809609 | 01 | CO | MEDICARE GROUP PTAN | OTHER |