Healthcare Provider Details

I. General information

NPI: 1023451176
Provider Name (Legal Business Name): KELLY JOY PETTIJOHN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 N FRANKLIN ST
DENVER CO
80205
US

IV. Provider business mailing address

10350 E DAKOTA AVE
DENVER CO
80247-1314
US

V. Phone/Fax

Practice location:
  • Phone: 303-338-4545
  • Fax: 303-344-7715
Mailing address:
  • Phone: 303-338-4545
  • Fax: 303-344-7715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberDR.0060683
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: