Basic Information
| Provider Information | |||||||||
| NPI: | 1427243971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KALISPELL REGINAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | THE CLINIC AT WAL-MART BY KRMC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CONWAY DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062124886 | ||||||||
| FaxNumber: | 4062572010 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 HUTTON RANCH ROAD | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599373112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067516533 | ||||||||
| FaxNumber: | 4062572010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 11/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | STJOHN | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | FNP | ||||||||
| AuthorizedOfficialTelephone: | 4067516533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN, FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 19254 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.