Provider Demographics
NPI:1083750731
Name:GRANDCHAMP, MILISSA RENEE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MILISSA
Middle Name:RENEE
Last Name:GRANDCHAMP
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-0880
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:406-745-3529
Practice Address - Street 1:5 4TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2117
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:406-745-3529
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT23008163W00000X
MTNUR-APRN-LIC-100330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse