Provider Demographics
NPI:1891801817
Name:ELLEN S DEWOLFE MSN P.C.
Entity Type:Organization
Organization Name:ELLEN S DEWOLFE MSN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEWOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN CNS
Authorized Official - Phone:065-497-3254
Mailing Address - Street 1:PO BOX 3138
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-3138
Mailing Address - Country:US
Mailing Address - Phone:406-549-7325
Mailing Address - Fax:406-549-7559
Practice Address - Street 1:125 BANK ST STE 310
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4413
Practice Address - Country:US
Practice Address - Phone:406-549-7325
Practice Address - Fax:406-549-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN16128364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000083014Medicare ID - Type Unspecified