Provider Demographics
NPI:1700972742
Name:DE SOUZA, MARY C (MSP ANP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:DE SOUZA
Suffix:
Gender:F
Credentials:MSP ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 SUNNYVIEW LN
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3156
Mailing Address - Country:US
Mailing Address - Phone:406-752-1790
Mailing Address - Fax:406-756-3529
Practice Address - Street 1:343 SUNNYVIEW LN
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3156
Practice Address - Country:US
Practice Address - Phone:406-752-1790
Practice Address - Fax:406-756-3529
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN26302363LA2200X
MT26302364SA2200X
MT101363363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT011004040Medicare PIN