1912008988 NPI number — MRS. MELINDA CECILE EKHOLM ARNP

Table of content: MRS. MELINDA CECILE EKHOLM ARNP (NPI 1912008988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912008988 NPI number — MRS. MELINDA CECILE EKHOLM ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EKHOLM
Provider First Name:
MELINDA
Provider Middle Name:
CECILE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLEDGE
Provider Other First Name:
MELINDA
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912008988
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3994 COLVILLE RD
Provider Second Line Business Mailing Address:
PO BOX 303
Provider Business Mailing Address City Name:
LOON LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99148-9789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-233-8412
Provider Business Mailing Address Fax Number:
509-233-2864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3994 COLVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOON LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99148-9789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-233-8412
Provider Business Practice Location Address Fax Number:
509-233-2864
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP30005591 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP2300X , with the licence number: RN00082739 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9629320 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143010 . This is a "LABOR & INDUSTRIES ID #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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