Provider Demographics
NPI:1063611150
Name:THEOBALD, KIMBERLY R (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 E 9TH AVE STE 740
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-3926
Mailing Address - Country:US
Mailing Address - Phone:720-941-1778
Mailing Address - Fax:
Practice Address - Street 1:4500 E 9TH AVE STE 740
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3926
Practice Address - Country:US
Practice Address - Phone:720-941-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO162312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily