Healthcare Provider Details

I. General information

NPI: 1730130337
Provider Name (Legal Business Name): LAURA C KISSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E BOULDER ST STE 600
COLORADO SPRINGS CO
80909-5533
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-364-6487
  • Fax: 719-364-8347
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number44538
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number200400694
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: