Basic Information
| Provider Information | |||||||||
| NPI: | 1114037389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANNIFAN | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 E ELIZABETH ST | ||||||||
| Address2: | THE YOUTH CLINIC | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702679510 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 E ELIZABETH ST | ||||||||
| Address2: | THE YOUTH CLINIC | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792679510 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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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 | 208000000X | ML20008677 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | 8131A | WY | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | 8131A | WY | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 0051721 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.