Basic Information
Provider Information | |||||||||
NPI: | 1841262557 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLEMYNS | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5920 MCINTYRE ST | ||||||||
Address2: |   | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 804037445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7204344876 | ||||||||
FaxNumber: | 3032254246 | ||||||||
Practice Location | |||||||||
Address1: | 5920 MCINTYRE ST | ||||||||
Address2: |   | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 80403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034344876 | ||||||||
FaxNumber: | 3032254246 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2006 | ||||||||
LastUpdateDate: | 10/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | APN.0004644-NP | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 16435231 | 05 | CO |   | MEDICAID |