Healthcare Provider Details

I. General information

NPI: 1316781743
Provider Name (Legal Business Name): DESTINY BULTENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 FAIRMONT BLVD
RAPID CITY SD
57701-7375
US

IV. Provider business mailing address

353 FAIRMONT BLVD
RAPID CITY SD
57701-7375
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-2300
  • Fax:
Mailing address:
  • Phone: 605-755-2300
  • Fax: 605-755-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP003749
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR051099
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberR051099
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: