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General NPI Number Information
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NPI Number | 1891600813
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Entity Type | Individual
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Provider Name | AMELIA GRACE FORMAN CPM, LM, DEM
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Gender | Female
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Dates
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Enumeration Date | 08/14/2026
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Last Update Date | 08/14/2026
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Provider Practice Location Address
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Address Line | 39907 MOUNTAIN VIEW RD
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City | POLSON
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State | MT
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Zip | 59860-7344
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Country | US
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Telephone | 406-546-8936
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Fax | 406-546-8936
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Provider Business Mailing Address
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Address Line | 39907 MOUNTAIN VIEW RD
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City | POLSON
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State | MT
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Zip | 59860-7344
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Country | US
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Telephone |
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Fax |
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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 | 176B00000X
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Taxonomy Name | Midwife
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License Number | AHC-MID-LIC-131816
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License Number State | MT
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