Healthcare Provider Details

I. General information

NPI: 1740264993
Provider Name (Legal Business Name): MARILYN R. SCOTT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 BLACK COLE DRIVE
FORT WASHAKIE WY
82514
US

IV. Provider business mailing address

28 BLACK COLE DRIVE
FORT WASHAKIE WY
82514
US

V. Phone/Fax

Practice location:
  • Phone: 377-335-5983
  • Fax:
Mailing address:
  • Phone: 377-335-5983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209000504
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: