Healthcare Provider Details

I. General information

NPI: 1104549039
Provider Name (Legal Business Name): DALLAS COTTAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 W SECOND ST
MOUNTAIN VIEW WY
82939
US

IV. Provider business mailing address

PO BOX 130
MOUNTAIN VIEW WY
82939-0130
US

V. Phone/Fax

Practice location:
  • Phone: 307-782-3377
  • Fax: 307-782-6466
Mailing address:
  • Phone: 307-782-3377
  • Fax: 307-782-6466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number20583
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: