Provider Demographics
NPI:1083865612
Name:DISSE, MEGAN LEIGH (PMHNP-BC, CNP)
Entity type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:LEIGH
Last Name:DISSE
Suffix:
Gender:F
Credentials:PMHNP-BC, CNP
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LEIGH
Other - Last Name:BEUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:23619 TIGERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HILL CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57745-6506
Mailing Address - Country:US
Mailing Address - Phone:218-849-6433
Mailing Address - Fax:
Practice Address - Street 1:804 WEST BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3577
Practice Address - Country:US
Practice Address - Phone:605-716-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR055739163W00000X
SDCP003456363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse