Healthcare Provider Details

I. General information

NPI: 1437717360
Provider Name (Legal Business Name): NICOLE MARIE BOTHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 LOUISIANA AVE STE 1
LIBBY MT
59923-2159
US

IV. Provider business mailing address

308 LOUISIANA AVE STE 1
LIBBY MT
59923-2159
US

V. Phone/Fax

Practice location:
  • Phone: 406-283-6800
  • Fax:
Mailing address:
  • Phone: 406-283-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number145254
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNUR-APRN-APP-144934
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: