Basic Information
Provider Information | |||||||||
NPI: | 1679710321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHELAN | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: | K. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.N.,M.S.N., N.N.P | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5445 DTC PKWY STE 700 | ||||||||
Address2: |   | ||||||||
City: | GREENWOOD VILLAGE | ||||||||
State: | CO | ||||||||
PostalCode: | 801113052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3038397440 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | SKY RIDGE MEDICAL CENTER | ||||||||
Address2: | 10101 RIDGEGATE PARKWAY | ||||||||
City: | LONE TREE | ||||||||
State: | CO | ||||||||
PostalCode: | 80124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7202252200 | ||||||||
FaxNumber: | 7202252269 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2009 | ||||||||
LastUpdateDate: | 02/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WN0002X | 71062 | CO | N |   | Nursing Service Providers | Registered Nurse | Neonatal Intensive Care | 363LN0000X | 5375036111 | KS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LN0000X | RN0071062 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
ID | Type | State | Issuer | Description | 1679710321 | 05 | CO |   | MEDICAID |