Provider Demographics
NPI:1063739704
Name:RAFACZ, RUTHANN (NP)
Entity type:Individual
Prefix:MS
First Name:RUTHANN
Middle Name:
Last Name:RAFACZ
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 1:468 MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:ID
Mailing Address - Zip Code:83804-8544
Mailing Address - Country:US
Mailing Address - Phone:208-437-0780
Mailing Address - Fax:
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:406-345-8901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT178334363LP0808X
ID970A364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology