Basic Information
| Provider Information | |||||||||
| NPI: | 1790179448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILCULLEN | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9049 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803019049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034154157 | ||||||||
| FaxNumber: | 3037763109 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 KEN PRATT BLVD STE 104A | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805016568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034154157 | ||||||||
| FaxNumber: | 3037763109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2015 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | APN.0091467 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 97978353 | 05 | CO | MEDICAID |