Basic Information
| Provider Information | |||||||||
| NPI: | 1366671331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORNBAKER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOLPERT | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | GENERAL DELIVERY | ||||||||
| Address2: | |||||||||
| City: | GRANBY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804469999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027796075 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 GRANBY PARK DRIVE SOUTH | ||||||||
| Address2: | |||||||||
| City: | GRANBY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708875800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2009 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 101100 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.