Basic Information
| Provider Information | |||||||||
| NPI: | 1245558071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDENBERG-HARRISON | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANDENBERG | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | MONTGOMERY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4863 N NEVADA AVE | ||||||||
| Address2: | STE 250 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706837107 | ||||||||
| FaxNumber: | 9702553963 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703286969 | ||||||||
| FaxNumber: | 9703286329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2010 | ||||||||
| LastUpdateDate: | 09/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1617657 | CO | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 990504 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.