Basic Information
| Provider Information | |||||||||
| NPI: | 1659343143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAFOLLETTE | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOURNE | ||||||||
| OtherFirstName: | GRACE | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2400 S. MINNESOTA AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571053762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 W 69TH ST | ||||||||
| Address2: | STE. 1500 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053225700 | ||||||||
| FaxNumber: | 6053225704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 12/11/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CP000282 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | CP000282 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 46022474352 | 05 | NE | MEDICAID | 142419 | 01 | MN | UCARE | OTHER | 6826732 | 05 | SD | MEDICAID | 0040478 | 01 | SD | BLUE CROSS | OTHER | 12200 | 05 | ND | MEDICAID | 140M7BO | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | 25216 | 01 | SD | SANFORD HEALTH PLAN | OTHER | 690718100 | 05 | MN | MEDICAID | 9233298 | 01 | SD | DAKOTACARE | OTHER | 15766 | 01 | SD | MIDLANDS CHOICE | OTHER | 22591 | 01 | IA | BLUE CROSS | OTHER | 500002297 | 05 | MN | MEDICAID | 500026048 | 01 | SD | RR MEDICARE | OTHER | HP37123 | 01 | SD | HEALTHPARTNERS | OTHER | 1663494 | 01 | SD | ARAZ/ AMERICA'S PPO | OTHER | 412991028069 | 01 | SD | PREFERRED ONE | OTHER | 1958108 | 05 | IA | MEDICAID | 57108C022 | 01 | SD | TRICARE | OTHER |