Healthcare Provider Details

I. General information

NPI: 1851099774
Provider Name (Legal Business Name): PATRICIA WILES CMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NORTH ST
RAPID CITY SD
57701-1163
US

IV. Provider business mailing address

350 ELK ST
RAPID CITY SD
57701-7351
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-0650
  • Fax:
Mailing address:
  • Phone: 605-343-7262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number1036359
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: