Provider Demographics
NPI:1962521799
Name:SQUIRES, KIM (NP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SQUIRES
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:PO BOX 350005
Mailing Address - Street 2:
Mailing Address - City:GRANTSDALE
Mailing Address - State:MT
Mailing Address - Zip Code:59835-0005
Mailing Address - Country:US
Mailing Address - Phone:406-375-6676
Mailing Address - Fax:
Practice Address - Street 1:205 BEDFORD ST
Practice Address - Street 2:SUITE L
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2853
Practice Address - Country:US
Practice Address - Phone:406-375-6671
Practice Address - Fax:406-375-6680
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3500952Medicaid