=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104691062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY ROSE RUNYON CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2023
-----------------------------------------------------
Last Update Date | 11/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 W 16TH AVE
-----------------------------------------------------
City | TYNDALL
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57066-2318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-589-2190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 441 WILLIAMS ST
-----------------------------------------------------
City | SCOTLAND
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57059-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-202-0094
-----------------------------------------------------
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 | CP003030
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------