Healthcare Provider Details

I. General information

NPI: 1972733947
Provider Name (Legal Business Name): MARY LOU IVERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S 27TH ST
BILLINGS MT
59101-4200
US

IV. Provider business mailing address

123 S 27TH ST
BILLINGS MT
59101-4200
US

V. Phone/Fax

Practice location:
  • Phone: 406-247-3350
  • Fax: 406-247-3307
Mailing address:
  • Phone: 406-247-3350
  • Fax: 406-247-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number11364
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: