Healthcare Provider Details

I. General information

NPI: 1710258579
Provider Name (Legal Business Name): KELLEY L REBERRY PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 RAMPART WAY SUITE 100
DENVER CO
80230-6429
US

IV. Provider business mailing address

125 RAMPART WAY SUITE 100
DENVER CO
80230-6429
US

V. Phone/Fax

Practice location:
  • Phone: 720-858-7600
  • Fax: 720-858-7610
Mailing address:
  • Phone: 720-858-7600
  • Fax: 720-858-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2111
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3760
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: