=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063116093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLETTE KATHRYN GORDER MS, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2023
-----------------------------------------------------
Last Update Date | 03/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2820 MOUNT RUSHMORE RD
-----------------------------------------------------
City | RAPID CITY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57701-5474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-342-3280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2749 W SAINT ANNE ST
-----------------------------------------------------
City | RAPID CITY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57702-4271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-415-0239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CP002733
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------