Provider Demographics
NPI:1174587216
Name:HERBENER-KALLAL, TAMARA LYNN (FNP-BC)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
Last Name:HERBENER-KALLAL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-8510
Mailing Address - Country:US
Mailing Address - Phone:970-625-6487
Mailing Address - Fax:
Practice Address - Street 1:501 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-8510
Practice Address - Country:US
Practice Address - Phone:970-625-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.002007-NP363LP2300X
COAPN.0002007-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07744238Medicaid
CO07744238Medicaid
COCG5748Medicare UPIN