Healthcare Provider Details

I. General information

NPI: 1073955449
Provider Name (Legal Business Name): ANITA RAE SMALL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHEYENNE AVENUE
LAME DEER MT
59043
US

IV. Provider business mailing address

PO BOX 203
BUSBY MT
59016-0203
US

V. Phone/Fax

Practice location:
  • Phone: 406-477-4400
  • Fax: 406-477-8204
Mailing address:
  • Phone: 406-477-4400
  • Fax: 406-477-8204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN25765
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: