Healthcare Provider Details

I. General information

NPI: 1942775713
Provider Name (Legal Business Name): REBEKAH RUTH STORM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 1ST AVE SE
WATERTOWN SD
57201-4499
US

IV. Provider business mailing address

506 1ST AVE SE
WATERTOWN SD
57201-4499
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-8482
  • Fax: 605-884-4300
Mailing address:
  • Phone: 605-886-8482
  • Fax: 605-884-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001470
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: