Healthcare Provider Details

I. General information

NPI: 1255646444
Provider Name (Legal Business Name): ALEXIS BRANDENBURG NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 13TH AVE E
POLSON MT
59860-5315
US

IV. Provider business mailing address

6 13TH AVE E
POLSON MT
59860-5315
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-5377
  • Fax:
Mailing address:
  • Phone: 406-883-5377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14141
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: