Provider Demographics
NPI:1790253953
Name:BRANDENBURG, MICHELLE MARIE (RN, CNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-2509
Mailing Address - Country:US
Mailing Address - Phone:605-352-8691
Mailing Address - Fax:605-352-8704
Practice Address - Street 1:111 4TH ST SE
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-2509
Practice Address - Country:US
Practice Address - Phone:605-352-8691
Practice Address - Fax:605-352-8704
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR024746163W00000X
SDCP001495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCP001495OtherSOUTH DAKOTA BOARD OF NURSING