MEDICARE: KWAKE PMH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1184587941
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KWAKE PMH

Provider Business Mailing Address
First Line	:	115 WILCOX ST
Second Line	:	ST 200
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104
Country	:	US
Telephone Number	:	720-824-3324
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 WILCOX ST
Second Line	:	ST 200
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104
Country	:	US
Telephone Number	:	720-824-3324
Fax Number	:

Authorized Official
Title or Position	:	PMHNP
Name	:	KATHLEEN SHEEREN WAKEFIELD
Credential	:	APN, NP, RN
Telephone Number	:	720-935-0291

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	12/08/2025

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