Healthcare Provider Details

I. General information

NPI: 1750001970
Provider Name (Legal Business Name): KENZIE SUZETTE GANT DNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WASHINGTON AVE NW
WAGNER SD
57380-4300
US

IV. Provider business mailing address

610 MAIN AVE
GEDDES SD
57342-2206
US

V. Phone/Fax

Practice location:
  • Phone: 605-384-3621
  • Fax:
Mailing address:
  • Phone: 605-212-8495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP002187
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCP002187
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: