Provider Demographics
NPI:1932349552
Name:BRUDOS-NOCKELS, KELLEE ANN (RPT)
Entity type:Individual
Prefix:
First Name:KELLEE
Middle Name:ANN
Last Name:BRUDOS-NOCKELS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19039 W. 88TH DRIVE
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80007-7302
Mailing Address - Country:US
Mailing Address - Phone:720-232-8443
Mailing Address - Fax:303-467-2866
Practice Address - Street 1:19039 W. 88TH DRIVE
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80007-7302
Practice Address - Country:US
Practice Address - Phone:720-232-8443
Practice Address - Fax:303-467-2866
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-21
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47050560Medicaid