Provider Demographics
NPI:1538408729
Name:SANDBERG, KELLY LYNN (NP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 173891
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3891
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0990636363LC1500X
COAPN.0990636-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34834320Medicaid
CO34834320Medicaid