Healthcare Provider Details

I. General information

NPI: 1396384301
Provider Name (Legal Business Name): TRACY METULLY ROBERTS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MT HIGHWAY 91 S
DILLON MT
59725-7379
US

IV. Provider business mailing address

213 CRYSTAL LN
DILLON MT
59725-7232
US

V. Phone/Fax

Practice location:
  • Phone: 406-683-3000
  • Fax:
Mailing address:
  • Phone: 406-671-2633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-APRN-LIC-155396
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: