Basic Information
| Provider Information | |||||||||
| NPI: | 1558621805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BISHARD | ||||||||
| FirstName: | KALEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP-BC, RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORNELLI | ||||||||
| OtherFirstName: | KALEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PMHNP-BC, RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4856 INNOVATION DR STE B | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805255540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704944200 | ||||||||
| FaxNumber: | 9706134475 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 CENTRE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805261842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704944200 | ||||||||
| FaxNumber: | 9703998037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2012 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | C-RXN.0001087-C-NP | CO | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN-204924 | CO | N | Nursing Service Providers | Registered Nurse | 163W00000X | 28186184A | IN | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 0990416 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | C-APN.0002416-C-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.