Healthcare Provider Details

I. General information

NPI: 1407309529
Provider Name (Legal Business Name): ARDIS ILENE MOELLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W PARK ST
BRANDON SD
57005-2300
US

IV. Provider business mailing address

300 S SPLITROCK BLVD
BRANDON SD
57005-1652
US

V. Phone/Fax

Practice location:
  • Phone: 605-582-6035
  • Fax: 605-582-6036
Mailing address:
  • Phone: 605-582-3446
  • Fax: 605-582-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR035496
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: