Healthcare Provider Details

I. General information

NPI: 1891600813
Provider Name (Legal Business Name): AMELIA GRACE FORMAN CPM, LM, DEM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39907 MOUNTAIN VIEW RD
POLSON MT
59860-7344
US

IV. Provider business mailing address

39907 MOUNTAIN VIEW RD
POLSON MT
59860-7344
US

V. Phone/Fax

Practice location:
  • Phone: 406-546-8936
  • Fax: 406-546-8936
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberAHC-MID-LIC-131816
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: