Healthcare Provider Details

I. General information

NPI: 1619063252
Provider Name (Legal Business Name): MARDONNA R HULM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARDI R HULM CNP

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 COMANCHE RD
FORT MEADE SD
57741-1002
US

IV. Provider business mailing address

16060 226TH ST
NEW UNDERWOOD SD
57761-6124
US

V. Phone/Fax

Practice location:
  • Phone: 605-347-2451
  • Fax: 605-720-7286
Mailing address:
  • Phone: 605-347-2511
  • Fax: 605-720-7286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRO18353
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: