Healthcare Provider Details

I. General information

NPI: 1194843870
Provider Name (Legal Business Name): MICHELLE LYNN BOLTZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E 3RD ST
LIBBY MT
59923-2056
US

IV. Provider business mailing address

214 E 3RD ST
LIBBY MT
59923-2056
US

V. Phone/Fax

Practice location:
  • Phone: 406-293-9274
  • Fax: 406-293-9280
Mailing address:
  • Phone: 406-293-9274
  • Fax: 406-293-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number957
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number40325
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: