Healthcare Provider Details

I. General information

NPI: 1487207122
Provider Name (Legal Business Name): TARA JANE WILLOUGHBY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 W PARK ST
BUTTE MT
59701-1713
US

IV. Provider business mailing address

1321 WYOMING ST
MISSOULA MT
59801-1725
US

V. Phone/Fax

Practice location:
  • Phone: 406-497-9000
  • Fax: 406-723-7117
Mailing address:
  • Phone: 406-532-8400
  • Fax: 406-224-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number142868
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number142868
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: