Basic Information
| Provider Information | |||||||||
| NPI: | 1962401372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLOTTA | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 649 | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599220649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068572997 | ||||||||
| FaxNumber: | 4065872996 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 DEER CREEK RD | ||||||||
| Address2: | |||||||||
| City: | SOMERS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068572997 | ||||||||
| FaxNumber: | 4068572996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/18/2006 | ||||||||
| NPIReactivationDate: | 08/15/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 020838 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0037108 | 01 | MT | MONTANA BCBS NUMBER | OTHER | 0434707 | 05 | MT | MEDICAID |