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General NPI Number Information
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NPI Number | 1487339750
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Entity Type | Organization
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Legal Business Name | WELLSPRING HEALTH AND AESTHETICS PLLC
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Dates
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Enumeration Date | 06/15/2023
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Last Update Date | 10/06/2023
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Provider Practice Location Address
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Address Line | 500 W BROADWAY ST FL 4
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City | MISSOULA
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State | MT
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Zip | 59802-4008
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Country | US
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Telephone | 406-370-1600
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Fax | 406-493-0333
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Provider Business Mailing Address
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Address Line | 122 DALY AVE
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City | MISSOULA
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State | MT
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Zip | 59801-4212
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Country | US
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Telephone | 815-482-9859
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Fax |
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Authorized Official
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Title or Position | PLASTIC AND RECONSTRUCTIVE SURGEON
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Name | DR. STEPHANIE SUPRENANT
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Credential | MD
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Telephone | 406-370-1600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2082S0099X
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Taxonomy Name | Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2082S0105X
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Taxonomy Name | Surgery of the Hand (Plastic Surgery) Physician
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License Number |
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Taxonomy #3
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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