Healthcare Provider Details

I. General information

NPI: 1396469110
Provider Name (Legal Business Name): ELIZABETH WHITESELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3876 E BEARTOOTH LOOP
SPEARFISH SD
57783-7714
US

IV. Provider business mailing address

3876 E BEARTOOTH LOOP
SPEARFISH SD
57783-7714
US

V. Phone/Fax

Practice location:
  • Phone: 605-430-2630
  • Fax:
Mailing address:
  • Phone: 605-430-2630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: