Healthcare Provider Details

I. General information

NPI: 1104062314
Provider Name (Legal Business Name): EQUALITY STATE INFECTION FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 E 2ND ST STE 200
CASPER WY
82609-4330
US

IV. Provider business mailing address

5810 E 2ND ST STE 200
CASPER WY
82609-4330
US

V. Phone/Fax

Practice location:
  • Phone: 307-234-8710
  • Fax: 307-237-0326
Mailing address:
  • Phone: 307-234-8710
  • Fax: 307-237-0326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA MARIE WILLETTE
Title or Position: COO, CFO
Credential: RN
Phone: 307-234-8710