Basic Information
| Provider Information | |||||||||
| NPI: | 1427623891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FETTIG | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | TAYLOR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 S 27TH ST | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591014227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062473350 | ||||||||
| FaxNumber: | 4062473389 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 S 27TH ST | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591014227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062473350 | ||||||||
| FaxNumber: | 4062473389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2021 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.