Healthcare Provider Details

I. General information

NPI: 1710605118
Provider Name (Legal Business Name): STACY WACHHOLTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY HECHT

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W 22ND ST STE 301
SIOUX FALLS SD
57105-1503
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-328-7700
  • Fax:
Mailing address:
  • Phone: 605-328-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number114358
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberCP002673
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: