Provider Demographics
NPI:1891184875
Name:BENNETT, KELLY (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6569 S OAK CIR
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-5859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7307 S REVERE PKWY STE 201
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-3931
Practice Address - Country:US
Practice Address - Phone:720-456-3989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004169363L00000X
TXAP127219363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376309601Medicaid
TX560580YNGSMedicare UPIN
TX560580YL7BMedicare UPIN