Provider Demographics
NPI:1275247199
Name:CARDIFF, CARISSA MARIE (APRN-FNP)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:MARIE
Last Name:CARDIFF
Suffix:
Gender:F
Credentials:APRN-FNP
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:MARIE
Other - Last Name:MAGGARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:7662 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHEPHERD
Mailing Address - State:MT
Mailing Address - Zip Code:59079-4130
Mailing Address - Country:US
Mailing Address - Phone:406-399-0379
Mailing Address - Fax:
Practice Address - Street 1:182 S 32ND ST W STE 5
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6887
Practice Address - Country:US
Practice Address - Phone:406-530-5096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-212012207Q00000X
MTRN-190701163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61440003OtherWASHINGTON STATE DEPARTMENT OF HEALTH