Provider Demographics
NPI:1003076639
Name:WESTON, NICOLETT M (APRN)
Entity type:Individual
Prefix:
First Name:NICOLETT
Middle Name:M
Last Name:WESTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:NICOLETT
Other - Middle Name:M
Other - Last Name:TWARDOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1224 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2338
Mailing Address - Country:US
Mailing Address - Phone:406-375-4823
Mailing Address - Fax:406-375-4846
Practice Address - Street 1:1037 MAIN ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:MT
Practice Address - Zip Code:59828-9374
Practice Address - Country:US
Practice Address - Phone:406-961-4661
Practice Address - Fax:406-961-4260
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT29947363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1003076639Medicaid
ID1003076639Medicaid
WA1003076639Medicaid
ID1003076639Medicaid