Provider Demographics
NPI:1659343143
Name:LAFOLLETTE, GRACE A (CNP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:LAFOLLETTE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:A
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:2400 S. MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-3762
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:4400 W 69TH ST
Practice Address - Street 2:STE. 1500
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8170
Practice Address - Country:US
Practice Address - Phone:605-322-5700
Practice Address - Fax:605-322-5704
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000282363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE46022474352Medicaid
MN142419OtherUCARE
SD6826732Medicaid
SD0040478OtherBLUE CROSS
ND12200Medicaid
MN140M7BOOtherCC SYSTEMS/ BLUE PLUS
SD25216OtherSANFORD HEALTH PLAN
MN690718100Medicaid
SD9233298OtherDAKOTACARE
SD15766OtherMIDLANDS CHOICE
IA22591OtherBLUE CROSS
MN500002297Medicaid
SD500026048OtherRR MEDICARE
SDHP37123OtherHEALTHPARTNERS
SD1663494OtherARAZ/ AMERICA'S PPO
SD412991028069OtherPREFERRED ONE
IA1958108Medicaid
SD57108C022OtherTRICARE
MN142419OtherUCARE
ND12200Medicaid