Healthcare Provider Details

I. General information

NPI: 1437231990
Provider Name (Legal Business Name): MICHELLE MARIE KLISMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15909 JACKSON CREEK PKWY
MONUMENT CO
80132-8693
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 719-488-9860
  • Fax: 719-488-9868
Mailing address:
  • Phone: 719-462-5600
  • Fax: 719-538-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0053709
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: