Healthcare Provider Details

I. General information

NPI: 1336062173
Provider Name (Legal Business Name): DANIELLE WEIDENBACH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 GALL ST.
LOWER BRULE SD
57548
US

IV. Provider business mailing address

PO BOX 497
HIGHMORE SD
57345-0497
US

V. Phone/Fax

Practice location:
  • Phone: 605-870-5526
  • Fax:
Mailing address:
  • Phone: 605-870-1474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number201279
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: