Healthcare Provider Details

I. General information

NPI: 1649005661
Provider Name (Legal Business Name): MARIAH SAGE KENNELL DNP-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAH SAGE KENNELL MENDOZA

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 11TH AVE
EVANS CO
80620-1011
US

IV. Provider business mailing address

2930 11TH AVE
EVANS CO
80620-1011
US

V. Phone/Fax

Practice location:
  • Phone: 970-353-9403
  • Fax:
Mailing address:
  • Phone: 970-353-9403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06262053
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1674236
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: