Provider Demographics
NPI:1619190519
Name:NYSTROM, JANICE LEA (RN, MSN, FNP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:LEA
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:RN, MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6850 UPPER BOX ELDER RD
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-0000
Mailing Address - Country:US
Mailing Address - Phone:406-395-4486
Mailing Address - Fax:406-395-4138
Practice Address - Street 1:6850 UPPER BOX ELDER RD
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-0000
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:406-395-4138
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN23489363LF0000X
MT40604803363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily