Healthcare Provider Details

I. General information

NPI: 1760479042
Provider Name (Legal Business Name): MARY BERNADETTE KENNY MOYNIHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7444 W ALASKA DR STE 250
LAKEWOOD CO
80226-3327
US

IV. Provider business mailing address

7444 W ALASKA DR STE 250
LAKEWOOD CO
80226-3327
US

V. Phone/Fax

Practice location:
  • Phone: 303-592-7284
  • Fax: 303-892-0601
Mailing address:
  • Phone: 303-592-7284
  • Fax: 303-892-0601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number34459
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: