Healthcare Provider Details

I. General information

NPI: 1083230304
Provider Name (Legal Business Name): MARIAH KELLAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date: 06/19/2023
Reactivation Date: 07/26/2023

III. Provider practice location address

419 PENNSYLVANIA ST
CHINOOK MT
59523-9726
US

IV. Provider business mailing address

419 PENNSYLVANIA ST
CHINOOK MT
59523-9726
US

V. Phone/Fax

Practice location:
  • Phone: 406-357-2294
  • Fax:
Mailing address:
  • Phone: 406-357-2294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-APRN-LIC-216413
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: