Provider Demographics
NPI:1558884064
Name:HERNDON, SHARON MARIE (MSN, RN, CNP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:MARIE
Last Name:HERNDON
Suffix:
Gender:F
Credentials:MSN, RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 N RESERVE ST STE 402
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1364
Mailing Address - Country:US
Mailing Address - Phone:406-493-3110
Mailing Address - Fax:
Practice Address - Street 1:2230 N RESERVE ST STE 402
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808
Practice Address - Country:US
Practice Address - Phone:406-493-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-126404363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1558884064Medicaid