Healthcare Provider Details

I. General information

NPI: 1255148151
Provider Name (Legal Business Name): KATIE ANNE HALVERSTADT RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 ARAPAHOE AVE
BOULDER CO
80303-9123
US

IV. Provider business mailing address

9247 W 87TH PL
ARVADA CO
80005-1243
US

V. Phone/Fax

Practice location:
  • Phone: 877-593-2454
  • Fax:
Mailing address:
  • Phone: 720-277-6901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number0198832
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: