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General NPI Number Information
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NPI Number | 1073208757
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Entity Type | Individual
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Provider Name | STACEY MARIE BURDETT FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 04/07/2023
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Last Update Date | 11/27/2023
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Provider Practice Location Address
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Address Line | 126 6TH AVE SW
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City | RONAN
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State | MT
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Zip | 59864-2600
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Country | US
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Telephone | 406-676-3600
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Fax | 406-676-3738
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Provider Business Mailing Address
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Address Line | 42543 PARK CIRCLE DR
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City | POLSON
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State | MT
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Zip | 59860-7533
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Country | US
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Telephone | 406-360-4263
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Fax | 406-883-5555
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 75899
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 214369
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License Number State | MT
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