Provider Demographics
NPI:1730412958
Name:KENNEDY, NICOLE DYAN (PA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DYAN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:DYAN
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:850 EAST HARVARD AVENUE
Mailing Address - Street 2:SUITE 285
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210
Mailing Address - Country:US
Mailing Address - Phone:303-777-3333
Mailing Address - Fax:303-733-4441
Practice Address - Street 1:850 EAST HARVARD AVENUE
Practice Address - Street 2:SUITE 285
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210
Practice Address - Country:US
Practice Address - Phone:303-777-3333
Practice Address - Fax:303-733-4441
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant