Provider Demographics
NPI:1508565631
Name:EGGERT, AMBER ROSE (CHW)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ROSE
Last Name:EGGERT
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WATERLOO ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-1656
Mailing Address - Country:US
Mailing Address - Phone:605-718-4870
Mailing Address - Fax:
Practice Address - Street 1:22 WATERLOO ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1656
Practice Address - Country:US
Practice Address - Phone:605-718-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCHW508172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1891823332Medicaid