Provider Demographics
NPI:1487008686
Name:TIBKE, SHELLY RAE (CNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RAE
Last Name:TIBKE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 E 20TH ST
Mailing Address - Street 2:STE 700
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1049
Mailing Address - Country:US
Mailing Address - Phone:605-334-0393
Mailing Address - Fax:605-334-0393
Practice Address - Street 1:911 E 20TH ST
Practice Address - Street 2:STE 700
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1049
Practice Address - Country:US
Practice Address - Phone:605-334-0393
Practice Address - Fax:605-334-0393
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR020920163W00000X
SDCP001053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse