Healthcare Provider Details

I. General information

NPI: 1093409799
Provider Name (Legal Business Name): KYLEE ANN ZIMBARDO CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLEE ANN ZIMBARDO RN

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

IV. Provider business mailing address

3518 BROOKSIDE DR
RAPID CITY SD
57702-2211
US

V. Phone/Fax

Practice location:
  • Phone: 605-355-2500
  • Fax:
Mailing address:
  • Phone: 605-484-5467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR049952
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR049952
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: