Healthcare Provider Details

I. General information

NPI: 1609459692
Provider Name (Legal Business Name): KELLY SHATTUCK BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 E DICKENSON PL
DENVER CO
80222-6012
US

IV. Provider business mailing address

4141 E DICKENSON PL
DENVER CO
80222-6012
US

V. Phone/Fax

Practice location:
  • Phone: 303-504-6500
  • Fax: 303-757-5245
Mailing address:
  • Phone: 303-504-6500
  • Fax: 303-757-5245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: