Healthcare Provider Details

I. General information

NPI: 1750806121
Provider Name (Legal Business Name): CARSON CHANELL GOMEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARSON CHANELL DAVILA

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 MAIN ST
STEVENSVILLE MT
59870-2828
US

IV. Provider business mailing address

704 MAIN ST
STEVENSVILLE MT
59870-2828
US

V. Phone/Fax

Practice location:
  • Phone: 406-303-9781
  • Fax: 888-440-2614
Mailing address:
  • Phone: 406-303-9781
  • Fax: 888-440-2614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number196690
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: