Provider Demographics
NPI:1194124420
Name:KNUDTSON, BRANDY
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:KNUDTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 854
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-0854
Mailing Address - Country:US
Mailing Address - Phone:970-578-9010
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 854
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-0854
Practice Address - Country:US
Practice Address - Phone:970-578-9010
Practice Address - Fax:970-578-9027
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0200392163W00000X
COAPN.0998741-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse