Provider Demographics
NPI:1366872004
Name:DEETER, KELLI SUSANN (FNP-BC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:SUSANN
Last Name:DEETER
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 1:295 MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3442
Mailing Address - Country:US
Mailing Address - Phone:970-389-5537
Mailing Address - Fax:
Practice Address - Street 1:6455 YOSEMITE ST, 6TH FLOOR
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111
Practice Address - Country:US
Practice Address - Phone:303-692-1211
Practice Address - Fax:844-434-0379
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2013103096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily