Healthcare Provider Details

I. General information

NPI: 1871042622
Provider Name (Legal Business Name): AMANDA BARRY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3006 TOWER RD
RAPID CITY SD
57701-5392
US

IV. Provider business mailing address

3006 TOWER RD
RAPID CITY SD
57701-5392
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-7295
  • Fax: 605-343-0138
Mailing address:
  • Phone: 605-343-7295
  • Fax: 605-343-0138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR039093
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001135
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: