=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174639199
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN S DEWOLFE MSN PC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 BANK ST STE 310
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59802-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-549-7325
-----------------------------------------------------
Fax | 406-549-7559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3138
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59806-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-549-7325
-----------------------------------------------------
Fax | 406-549-7559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | RN16128
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------