Healthcare Provider Details

I. General information

NPI: 1124375712
Provider Name (Legal Business Name): MARINA FAITH MITCHELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHEYENNE AVE
LAME DEER MT
59043
US

IV. Provider business mailing address

BOX 67, 100 CHEYENNE AVE
LAME DEER MT
59043
US

V. Phone/Fax

Practice location:
  • Phone: 406-477-4400
  • Fax: 406-477-3038
Mailing address:
  • Phone: 406-477-4400
  • Fax: 406-477-3038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN28519
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: