Provider Demographics
NPI:1942875166
Name:PRAIRIE PHOENIX PLLC
Entity Type:Organization
Organization Name:PRAIRIE PHOENIX PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ABBEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KITTO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:605-428-3040
Mailing Address - Street 1:330 W 10TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:DELL RAPIDS
Mailing Address - State:SD
Mailing Address - Zip Code:57022-1524
Mailing Address - Country:US
Mailing Address - Phone:605-428-3040
Mailing Address - Fax:
Practice Address - Street 1:120 N WIND ST
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1245
Practice Address - Country:US
Practice Address - Phone:605-428-3040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-20
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD363LF0000XOtherLICENSE