Basic Information
| Provider Information | |||||||||
| NPI: | 1174682124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | NORWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814230280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703274233 | ||||||||
| FaxNumber: | 9703274228 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 S ASPEN ST | ||||||||
| Address2: | |||||||||
| City: | NORWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703274233 | ||||||||
| FaxNumber: | 9703274228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101240604 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0066881 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1174682124 | 05 | CA | MEDICAID |