Basic Information
| Provider Information | |||||||||
| NPI: | 1477516045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKELL | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLAKE | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13402 W COAL MINE AVE | ||||||||
| Address2: | STE 230 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801275407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037302167 | ||||||||
| FaxNumber: | 3039964820 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 W COUNTY LINE RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | HIGHLANDS RANCH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037955980 | ||||||||
| FaxNumber: | 3037957881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43043 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 020422 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 9000144571 | 05 | CO | MEDICAID | 403385YU8D | 01 | CO | GROUP MEMBER PTAN | OTHER |