Provider Demographics
NPI:1508174426
Name:OLD COYOTE, EDWINA MAE (RN)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:MAE
Last Name:OLD COYOTE
Suffix:
Gender:F
Credentials:RN
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 9
Mailing Address - Street 2:
Mailing Address - City:CROW AGENCY
Mailing Address - State:MT
Mailing Address - Zip Code:59022-0009
Mailing Address - Country:US
Mailing Address - Phone:406-683-3500
Mailing Address - Fax:
Practice Address - Street 1:1010 SOUTH 7650 EAST
Practice Address - Street 2:
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022
Practice Address - Country:US
Practice Address - Phone:406-638-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT35208163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse