Provider Demographics
NPI:1700065208
Name:MYLANT, MARYLOU (PHD, RN, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:MARYLOU
Middle Name:
Last Name:MYLANT
Suffix:
Gender:F
Credentials:PHD, RN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13716 GHOST CANYON RD
Mailing Address - Street 2:
Mailing Address - City:HERMOSA
Mailing Address - State:SD
Mailing Address - Zip Code:57744-5020
Mailing Address - Country:US
Mailing Address - Phone:605-394-6617
Mailing Address - Fax:605-394-1250
Practice Address - Street 1:1011 11TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3530
Practice Address - Country:US
Practice Address - Phone:605-394-6617
Practice Address - Fax:605-394-1250
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR025102364SP0810X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575492Medicaid