Provider Demographics
NPI:1790293116
Name:DOMIRE, JESSICA MARIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:DOMIRE
Suffix:
Gender:F
Credentials:APRN
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 581
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:MT
Mailing Address - Zip Code:59538-0581
Mailing Address - Country:US
Mailing Address - Phone:406-301-2357
Mailing Address - Fax:
Practice Address - Street 1:140 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:MT
Practice Address - Zip Code:59538
Practice Address - Country:US
Practice Address - Phone:406-654-1953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-146098363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily