Provider Demographics
NPI:1487959177
Name:BRISTOL, KATRINA DENESE
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:DENESE
Last Name:BRISTOL
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 1:6537 VESUVIUS RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-5307
Mailing Address - Country:US
Mailing Address - Phone:303-670-0731
Mailing Address - Fax:
Practice Address - Street 1:200 EXEMPLA CIR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3370
Practice Address - Country:US
Practice Address - Phone:303-689-4740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO63272363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal