Healthcare Provider Details

I. General information

NPI: 1700065208
Provider Name (Legal Business Name): MARYLOU MYLANT PHD, RN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 11TH ST
RAPID CITY SD
57701-3530
US

IV. Provider business mailing address

13716 GHOST CANYON RD
HERMOSA SD
57744-5020
US

V. Phone/Fax

Practice location:
  • Phone: 605-394-6617
  • Fax: 605-394-1250
Mailing address:
  • Phone: 605-394-6617
  • Fax: 605-394-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR025102
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR025102
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: