Provider Demographics
NPI:1639570419
Name:LIND, JUANITA
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:LIND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24276 AIRPORT RD,
Mailing Address - Street 2:24276 AIRPORT RD.
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625
Mailing Address - Country:US
Mailing Address - Phone:605-964-7724
Mailing Address - Fax:605-964-0545
Practice Address - Street 1:.24276 166TH AIRPORT RD.
Practice Address - Street 2:24276 166TH AIRPORT RD.
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-964-7724
Practice Address - Fax:605-964-0545
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDA009692376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide