Provider Demographics
NPI:1487339750
Name:WELLSPRING HEALTH AND AESTHETICS PLLC
Entity type:Organization
Organization Name:WELLSPRING HEALTH AND AESTHETICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PLASTIC AND RECONSTRUCTIVE SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPRENANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-370-1600
Mailing Address - Street 1:122 DALY AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4212
Mailing Address - Country:US
Mailing Address - Phone:815-482-9859
Mailing Address - Fax:
Practice Address - Street 1:500 W BROADWAY ST FL 4
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-370-1600
Practice Address - Fax:406-493-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-15
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Single Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty