Provider Demographics
NPI:1447373329
Name:PENTECOST, LISA ANN (CNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:PENTECOST
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:SEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 3450
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-3450
Mailing Address - Country:US
Mailing Address - Phone:605-719-8382
Mailing Address - Fax:605-719-4934
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-719-8382
Practice Address - Fax:605-719-4934
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2008-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0137363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR025334OtherRN LICENSE
SD6829780Medicaid
SD4993198OtherWELLMARK
SD0137OtherCNP LICENSE