Provider Demographics
NPI:1306127618
Name:WATERMAN, KELLY ROBIN (CNIM)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ROBIN
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 FLINT WAY
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2250
Mailing Address - Country:US
Mailing Address - Phone:651-324-3680
Mailing Address - Fax:303-962-4819
Practice Address - Street 1:220 FLINT WAY
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2250
Practice Address - Country:US
Practice Address - Phone:651-324-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1200OtherABRET CERTIFICATION