Provider Demographics
NPI:1043599277
Name:KIECKER, REBECCA ANN (NP-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:KIECKER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:BEYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-8311
Practice Address - Street 1:1720 SOUTH UNIVERSITY DRIVE
Practice Address - Street 2:SANFORD SOUTH UNIVERSITY
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:605-622-2745
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000658363L00000X
NDR29811363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner