Provider Demographics
NPI:1114037389
Name:HANNIFAN, KATHLEEN ANNE (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:HANNIFAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E ELIZABETH ST
Mailing Address - Street 2:THE YOUTH CLINIC
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4007
Mailing Address - Country:US
Mailing Address - Phone:970-267-9510
Mailing Address - Fax:
Practice Address - Street 1:1200 E ELIZABETH ST
Practice Address - Street 2:THE YOUTH CLINIC
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4007
Practice Address - Country:US
Practice Address - Phone:979-267-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20008677208000000X
WY8131A2080A0000X, 208000000X
CO0051721208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine