Basic Information
| Provider Information | |||||||||
| NPI: | 1023493939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELTO | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRANDON | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1065 NE 125TH STREET | ||||||||
| Address2: | SUITE 409 | ||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 3055037363 | ||||||||
| Practice Location | |||||||||
| Address1: | 6915 TUTT BLVD | ||||||||
| Address2: | SUITE 110B | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809233591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194451292 | ||||||||
| FaxNumber: | 7195916486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2015 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN.1617420 | CO | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | APN.0992076-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 21770085 | 05 | CO | MEDICAID |