Healthcare Provider Details

I. General information

NPI: 1164967774
Provider Name (Legal Business Name): STACY KRISTIN KOTALIK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 SUMMIT ST STE 2500
YANKTON SD
57078-3739
US

IV. Provider business mailing address

1104 W 8TH ST
YANKTON SD
57078-3306
US

V. Phone/Fax

Practice location:
  • Phone: 605-655-1710
  • Fax: 605-655-1711
Mailing address:
  • Phone: 605-665-7841
  • Fax: 605-665-0546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001147
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: