Provider Demographics
NPI:1720086200
Name:OTTOLENGHI, KIMBERLY SUE (CPNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:OTTOLENGHI
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:2001 S SHIELDS
Mailing Address - Street 2:BLDG G
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526
Mailing Address - Country:US
Mailing Address - Phone:970-484-4871
Mailing Address - Fax:970-482-4927
Practice Address - Street 1:2001 S SHIELDS
Practice Address - Street 2:BLDG G
Practice Address - City:FT. COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526
Practice Address - Country:US
Practice Address - Phone:970-484-4871
Practice Address - Fax:970-482-4927
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2899363L00000X
CO107622363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77129849Medicaid
CO77129849Medicaid