Healthcare Provider Details

I. General information

NPI: 1437401247
Provider Name (Legal Business Name): REBECCA RISTY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5019 S WESTERN AVE STE 200
SIOUX FALLS SD
57108-5155
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-328-9700
  • Fax: 605-328-9701
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-328-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000745
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: