Healthcare Provider Details

I. General information

NPI: 1306287057
Provider Name (Legal Business Name): RUSTIE CHANELLE LEGARDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 N 6TH ST W APT 2 730 NORTH 6TH ST WEST #2 MISSOULA, MT 59802
MISSOULA MT
59802-2845
US

IV. Provider business mailing address

PO BOX 2373 730 NORTH 6TH ST WEST #2 MISSOULA MONTANA 59802
MISSOULA MT
59806-2373
US

V. Phone/Fax

Practice location:
  • Phone: 406-493-2142
  • Fax:
Mailing address:
  • Phone: 406-493-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: