Basic Information
| Provider Information | |||||||||
| NPI: | 1700972742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE SOUZA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MSP ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 343 SUNNYVIEW LN | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067521790 | ||||||||
| FaxNumber: | 4067563529 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 SUNNYVIEW LN | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067521790 | ||||||||
| FaxNumber: | 4067563529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN26302 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 364SA2200X | 26302 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 363LA2200X | 101363 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.