Provider Demographics
NPI:1699545871
Name:HODGE, AMY (CNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 SAINT ANNE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-348-8000
Mailing Address - Fax:605-348-4315
Practice Address - Street 1:636 SAINT ANNE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4694
Practice Address - Country:US
Practice Address - Phone:605-348-8000
Practice Address - Fax:605-348-4315
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR052165363L00000X
SDCP003091363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner