Healthcare Provider Details

I. General information

NPI: 1396220802
Provider Name (Legal Business Name): MONIQUE MARIE SIOUX BOB RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER RD
KYLE SD
57752
US

IV. Provider business mailing address

PO BOX 540
KYLE SD
57752-0540
US

V. Phone/Fax

Practice location:
  • Phone: 605-455-8214
  • Fax: 605-455-2808
Mailing address:
  • Phone: 605-455-8214
  • Fax: 605-455-2808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR040627
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: