Basic Information
| Provider Information | |||||||||
| NPI: | 1992706873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 28TH ST S STE 6 | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594055296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067318888 | ||||||||
| FaxNumber: | 4067318876 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 28TH ST S | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594055296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067318888 | ||||||||
| FaxNumber: | 4067318876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN019691 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0434070 | 05 | MT | MEDICAID |