Healthcare Provider Details

I. General information

NPI: 1639879042
Provider Name (Legal Business Name): HEATHER COURAGE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 KANSAS CITY ST
RAPID CITY SD
57701-2884
US

IV. Provider business mailing address

300 KANSAS CITY ST
RAPID CITY SD
57701-2884
US

V. Phone/Fax

Practice location:
  • Phone: 605-641-6377
  • Fax:
Mailing address:
  • Phone: 605-641-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCP003008
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR043731
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: