Provider Demographics
NPI:1871869057
Name:EVANS-HULLINGER, KELLY MARIE (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:EVANS-HULLINGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:720-754-8134
Mailing Address - Fax:303-869-2258
Practice Address - Street 1:1721 E 19TH AVE STE 520
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1243
Practice Address - Country:US
Practice Address - Phone:720-754-8134
Practice Address - Fax:303-869-2258
Is Sole Proprietor?:No
Enumeration Date:2012-04-01
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0055106207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO99688310Medicaid
CO99688310Medicaid