Healthcare Provider Details

I. General information

NPI: 1174279970
Provider Name (Legal Business Name): AMANDA JO DVANAJSCAK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE
SIOUX FALLS SD
57104-1335
US

IV. Provider business mailing address

1200 N WEST AVE
SIOUX FALLS SD
57104-1335
US

V. Phone/Fax

Practice location:
  • Phone: 605-339-0420
  • Fax:
Mailing address:
  • Phone: 605-339-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCP002320
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP002320
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: