Basic Information
Provider Information | |||||||||
NPI: | 1003076639 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WESTON | ||||||||
FirstName: | NICOLETT | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TWARDOSKI | ||||||||
OtherFirstName: | NICOLETT | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1224 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | MT | ||||||||
PostalCode: | 598402338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4063754823 | ||||||||
FaxNumber: | 4063754846 | ||||||||
Practice Location | |||||||||
Address1: | 1037 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CORVALLIS | ||||||||
State: | MT | ||||||||
PostalCode: | 598289374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4069614661 | ||||||||
FaxNumber: | 4069614260 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2008 | ||||||||
LastUpdateDate: | 11/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 29947 | MT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1003076639 | 05 | MT |   | MEDICAID | 1003076639 | 05 | ID |   | MEDICAID | 1003076639 | 05 | WA |   | MEDICAID |