Healthcare Provider Details

I. General information

NPI: 1487339750
Provider Name (Legal Business Name): WELLSPRING HEALTH AND AESTHETICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST FL 4
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

122 DALY AVE
MISSOULA MT
59801-4212
US

V. Phone/Fax

Practice location:
  • Phone: 406-370-1600
  • Fax: 406-493-0333
Mailing address:
  • Phone: 815-482-9859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHANIE SUPRENANT
Title or Position: PLASTIC AND RECONSTRUCTIVE SURGEON
Credential: MD
Phone: 406-370-1600