Provider Demographics
NPI:1306240445
Name:AFFOLDER, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:AFFOLDER
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 1:8450 DECATUR ST APT 113
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-3824
Mailing Address - Country:US
Mailing Address - Phone:303-513-7080
Mailing Address - Fax:
Practice Address - Street 1:12008 MELODY DR
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-4212
Practice Address - Country:US
Practice Address - Phone:303-255-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15492225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COAAA0543Medicare Oscar/Certification