Healthcare Provider Details

I. General information

NPI: 1174639199
Provider Name (Legal Business Name): ELLEN S DEWOLFE MSN PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BANK ST STE 310
MISSOULA MT
59802-4413
US

IV. Provider business mailing address

PO BOX 3138
MISSOULA MT
59806-3138
US

V. Phone/Fax

Practice location:
  • Phone: 406-549-7325
  • Fax: 406-549-7559
Mailing address:
  • Phone: 406-549-7325
  • Fax: 406-549-7559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberRN16128
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: