Healthcare Provider Details

I. General information

NPI: 1821166539
Provider Name (Legal Business Name): BEVERLEY ANN BLAKE ODOHERTY CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 26TH ST S
GREAT FALLS MT
59405-5161
US

IV. Provider business mailing address

1278 SWISHER RD
POCATELLO ID
83204-1929
US

V. Phone/Fax

Practice location:
  • Phone: 406-455-5000
  • Fax: 406-731-8318
Mailing address:
  • Phone: 208-705-7554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP925A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPPA070938
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201907779NP-PP
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number102700
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: