1750383287 NPI number — DENISE G GRESHAM FNP

Table of content: DENISE G GRESHAM FNP (NPI 1750383287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750383287 NPI number — DENISE G GRESHAM FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRESHAM
Provider First Name:
DENISE
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STIMAC
Provider Other First Name:
DENISE
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1750383287
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2517 7TH AVE S
Provider Second Line Business Mailing Address:
STE B3
Provider Business Mailing Address City Name:
GREAT FALLS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59405-3033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-315-3503
Provider Business Mailing Address Fax Number:
406-315-3505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2517 7TH AVE S
Provider Second Line Business Practice Location Address:
B-3
Provider Business Practice Location Address City Name:
GREAT FALLS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59405-3032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-315-3503
Provider Business Practice Location Address Fax Number:
406-315-3505
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN019237 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0434148 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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