Healthcare Provider Details

I. General information

NPI: 1902933971
Provider Name (Legal Business Name): KATHLEEN J PRUDLO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 SHERIDAN BLVD
WESTMINSTER CO
80003-2605
US

IV. Provider business mailing address

12398 W 70TH AVE
ARVADA CO
80004-2334
US

V. Phone/Fax

Practice location:
  • Phone: 303-657-6538
  • Fax:
Mailing address:
  • Phone: 303-424-5167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number103074
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: