Basic Information
| Provider Information | |||||||||
| NPI: | 1104297357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEARN | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | CAROLYN | ||||||||
| OtherMiddleName: | SUZANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5450 WESTERN AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803012709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034155199 | ||||||||
| FaxNumber: | 3034155198 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 SUPERIOR DR STE 100A | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034155255 | ||||||||
| FaxNumber: | 3034155256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2015 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
| 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 | 363L00000X | APN.0991877-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.