Healthcare Provider Details

I. General information

NPI: 1114037389
Provider Name (Legal Business Name): KATHLEEN ANNE HANNIFAN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E ELIZABETH ST THE YOUTH CLINIC
FORT COLLINS CO
80524-4007
US

IV. Provider business mailing address

1200 E ELIZABETH ST THE YOUTH CLINIC
FORT COLLINS CO
80524-4007
US

V. Phone/Fax

Practice location:
  • Phone: 979-267-9510
  • Fax:
Mailing address:
  • Phone: 970-267-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberML20008677
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number8131A
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8131A
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0051721
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: