Provider Demographics
NPI:1457424244
Name:PONTORIERO, CHARLENE (NP)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:
Last Name:PONTORIERO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 DILWORTH ST
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-2053
Mailing Address - Country:US
Mailing Address - Phone:406-345-8935
Mailing Address - Fax:406-345-8908
Practice Address - Street 1:107 DILWORTH ST
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-2053
Practice Address - Country:US
Practice Address - Phone:406-345-8935
Practice Address - Fax:406-345-8908
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR30872363LF0000X
MT23960363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000063062OtherBLUE CROSS OF MT
ND005027Medicaid
MT0720161Medicaid
MT0720161Medicaid
500024487Medicare ID - Type UnspecifiedRAILROAD
MT273978Medicare ID - Type Unspecified