Healthcare Provider Details

I. General information

NPI: 1770032336
Provider Name (Legal Business Name): MICHELLE JANIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EAST HIGHWAY 18 BOX 1201
PINE RIDGE SD
57770-1201
US

IV. Provider business mailing address

PO BOX 540
PINE RIDGE SD
57770-0540
US

V. Phone/Fax

Practice location:
  • Phone: 605-867-5131
  • Fax:
Mailing address:
  • Phone: 605-441-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR047835
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: