Provider Demographics
NPI:1699872010
Name:SUZANNE C GULLOTTA
Entity type:Organization
Organization Name:SUZANNE C GULLOTTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GULLOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:406-857-2997
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:MT
Mailing Address - Zip Code:59922-0649
Mailing Address - Country:US
Mailing Address - Phone:406-857-2997
Mailing Address - Fax:
Practice Address - Street 1:77 DEER CREEK ROAD
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:MT
Practice Address - Zip Code:59932
Practice Address - Country:US
Practice Address - Phone:406-857-2997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT020838363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT037108OtherBCBS
MT0434707Medicaid
MT0434707Medicaid
MT000084234Medicare PIN