Provider Demographics
NPI:1174639199
Name:DEWOLFE, ELLEN S (MSN PC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:S
Last Name:DEWOLFE
Suffix:
Gender:F
Credentials:MSN PC
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 3138
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-3138
Mailing Address - Country:US
Mailing Address - Phone:406-549-7325
Mailing Address - Fax:406-549-7559
Practice Address - Street 1:125 BANK ST STE 310
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4413
Practice Address - Country:US
Practice Address - Phone:406-549-7325
Practice Address - Fax:406-549-7559
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN16128364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000098073OtherBC/BS
MT890000386OtherRAILROAD MEDICARE
MT4300153Medicaid
MT4300153Medicaid
MT000098073OtherBC/BS