Healthcare Provider Details

I. General information

NPI: 1689168049
Provider Name (Legal Business Name): KACIA BUNDLE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

PO BOX 7609
MISSOULA MT
59807-7609
US

V. Phone/Fax

Practice location:
  • Phone: 406-721-5600
  • Fax:
Mailing address:
  • Phone: 406-721-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number131029
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: