1578574067 NPI number — MS. DIANNE WICKHAM SAWITKE NURSE PRACTITIONER

Table of content: MS. DIANNE WICKHAM SAWITKE NURSE PRACTITIONER (NPI 1578574067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578574067 NPI number — MS. DIANNE WICKHAM SAWITKE NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAWITKE
Provider First Name:
DIANNE
Provider Middle Name:
WICKHAM
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WICKHAM
Provider Other First Name:
DIANNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NURSE PRACTITIONER
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578574067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 N MONTANA ST
Provider Second Line Business Mailing Address:
TRINA HEALTH OF MONTANA
Provider Business Mailing Address City Name:
DILLON
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59725-3315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-988-0721
Provider Business Mailing Address Fax Number:
406-988-0724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 N MONTANA ST
Provider Second Line Business Practice Location Address:
TRINA HEALTH OF MONTANA
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59725-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-988-0721
Provider Business Practice Location Address Fax Number:
406-988-0724
Provider Enumeration Date:
08/10/2006

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:  NUR-APRN-LIC-100581 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X , with the licence number: NUR-APRN-LIC-100581 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4305730 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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