Healthcare Provider Details

I. General information

NPI: 1568828226
Provider Name (Legal Business Name): MARY SHICK AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35401 MISSION DR
SAINT IGNATIUS MT
59865-7791
US

IV. Provider business mailing address

2835 FORT MISSOULA RD PHYSICIANS BUILDING NO. 3
MISSOULA MT
59804-7423
US

V. Phone/Fax

Practice location:
  • Phone: 406-745-3525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNUR-APRN-LIC-101616
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: