Healthcare Provider Details

I. General information

NPI: 1063470771
Provider Name (Legal Business Name): MICHELLE DANNETTE KECK REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12440 ELLINGWOOD PEAK PL
PEYTON CO
80831-4439
US

IV. Provider business mailing address

12440 ELLINGWOOD PEAK PL
PEYTON CO
80831-4439
US

V. Phone/Fax

Practice location:
  • Phone: 760-267-4115
  • Fax: 719-524-4075
Mailing address:
  • Phone: 719-526-7616
  • Fax: 719-524-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number0118827
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: