Provider Demographics
NPI:1285171090
Name:MIKOLAJ, KERRY (DPT)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:MIKOLAJ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 ARISTA PL
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4154
Mailing Address - Country:US
Mailing Address - Phone:720-777-9194
Mailing Address - Fax:
Practice Address - Street 1:8401 ARISTA PL
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-4154
Practice Address - Country:US
Practice Address - Phone:720-777-9194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0008950174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist