Healthcare Provider Details

I. General information

NPI: 1629016480
Provider Name (Legal Business Name): GAIL SUE WILD CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 13TH AVE
BELLE FOURCHE SD
57717
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN MEDICAL STAFF SERVICES
RAPID CITY SD
57701-6000
US

V. Phone/Fax

Practice location:
  • Phone: 605-892-2701
  • Fax: 605-644-4197
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0204
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR018558
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: