Provider Demographics
NPI:1285392779
Name:KOPACZ, KATHLEEN R (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:KOPACZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4911
Mailing Address - Country:US
Mailing Address - Phone:719-269-8820
Mailing Address - Fax:719-204-0230
Practice Address - Street 1:715 S 9TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4911
Practice Address - Country:US
Practice Address - Phone:719-269-8820
Practice Address - Fax:719-204-0230
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997105-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner