Healthcare Provider Details

I. General information

NPI: 1164708103
Provider Name (Legal Business Name): SHAMYNE HOVER DUMOUCHEL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 RIDGEWATER DR STE A
POLSON MT
59860-8977
US

IV. Provider business mailing address

320 SUNNYVIEW LN
KALISPELL MT
59901-3129
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-7441
  • Fax: 406-257-0304
Mailing address:
  • Phone: 406-752-7441
  • Fax: 406-257-0304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21349
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-APRN-LIC-174670
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: