Provider Demographics
NPI:1902985419
Name:DOLEZAL, KATHLEEN A (APRN PC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:DOLEZAL
Suffix:
Gender:F
Credentials:APRN PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 HELENA AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-3654
Mailing Address - Country:US
Mailing Address - Phone:406-442-3323
Mailing Address - Fax:
Practice Address - Street 1:616 HELENA AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3654
Practice Address - Country:US
Practice Address - Phone:406-442-3323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17403363LP0808X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4302479Medicaid
000083805Medicare ID - Type Unspecified