Healthcare Provider Details

I. General information

NPI: 1902927395
Provider Name (Legal Business Name): DELEEN JEAN KOUGL CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MAIN STREET
EAGLE BUTTE SD
57625
US

IV. Provider business mailing address

315 MAIN STREET
EAGLE BUTTE SD
57625
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-7700
  • Fax: 605-964-7701
Mailing address:
  • Phone: 605-964-7700
  • Fax: 605-964-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0316
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: