Provider Demographics
NPI:1962401372
Name:GULLOTTA, SUZANNE C (APRN)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:C
Last Name:GULLOTTA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:406-587-2996
Practice Address - Street 1:77 DEER CREEK RD
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:406-857-2996
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2007-07-09
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-08-15
Provider Licenses
StateLicense IDTaxonomies
MT020838363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0037108OtherMONTANA BCBS NUMBER
MT0434707Medicaid
MT0037108OtherMONTANA BCBS NUMBER
MTS36092Medicare UPIN