=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467957555
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER HATHAWAY NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2018
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1175 S PERRY ST STE 200
-----------------------------------------------------
City | CASTLE ROCK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80104-0015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-268-1571
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3445 FIRST LIGHT DR
-----------------------------------------------------
City | CASTLE ROCK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80109-7903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-393-2398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APN.0993776-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------