Healthcare Provider Details

I. General information

NPI: 1366763468
Provider Name (Legal Business Name): TINA RENEE KAUDERER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2010
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S PERRY ST STE 104B
CASTLE ROCK CO
80104-1950
US

IV. Provider business mailing address

1001 S PERRY ST STE 104B
CASTLE ROCK CO
80104-1950
US

V. Phone/Fax

Practice location:
  • Phone: 720-485-3178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0995983-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-11175
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: