Healthcare Provider Details

I. General information

NPI: 1043702244
Provider Name (Legal Business Name): NICOLE LYNN BAMBERG CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 200
FORT THOMPSON SD
57339-0200
US

IV. Provider business mailing address

PO BOX 200
FORT THOMPSON SD
57339-0200
US

V. Phone/Fax

Practice location:
  • Phone: 605-245-1546
  • Fax: 605-245-2600
Mailing address:
  • Phone: 605-245-1546
  • Fax: 605-245-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCP001381
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: