Basic Information
| Provider Information | |||||||||
| NPI: | 1831638386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIANINEJAD | ||||||||
| FirstName: | MARYEM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1345 PLAZA CT N | ||||||||
| Address2: | 1A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800263531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036653036 | ||||||||
| FaxNumber: | 7202060434 | ||||||||
| Practice Location | |||||||||
| Address1: | 8990 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802294537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209291655 | ||||||||
| FaxNumber: | 7202060434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2017 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN.0992933-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.