Healthcare Provider Details

I. General information

NPI: 1760074322
Provider Name (Legal Business Name): ALLISON ODATO ARMITAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE STE 229
JACKSON WY
83001-8640
US

IV. Provider business mailing address

PO BOX 428
JACKSON WY
83001-0428
US

V. Phone/Fax

Practice location:
  • Phone: 307-739-7690
  • Fax: 307-739-7644
Mailing address:
  • Phone: 307-739-7690
  • Fax: 307-739-7644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number47203
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: