Healthcare Provider Details

I. General information

NPI: 1164430658
Provider Name (Legal Business Name): ANGEL LEE WILSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BIA #1 SOLDIER CREEK RD
ROSEBUD SD
57570
US

IV. Provider business mailing address

PO BOX 1111
ROSEBUD SD
57570
US

V. Phone/Fax

Practice location:
  • Phone: 605-747-2231
  • Fax: 605-747-2216
Mailing address:
  • Phone: 605-747-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR024323
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: