Healthcare Provider Details

I. General information

NPI: 1285053314
Provider Name (Legal Business Name): MARY VERMILLION RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 WESTWOOD DR
HAMILTON MT
59840-2315
US

IV. Provider business mailing address

215 S 7TH ST
HAMILTON MT
59840-2667
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-8990
  • Fax:
Mailing address:
  • Phone: 406-880-2551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number72629
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number72629
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number72629
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number72629
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: