Provider Demographics
NPI:1417288572
Name:EGHOLM, NICOLE RUBY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RUBY
Last Name:EGHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43335 KALIFORNSKY BEACH RD STE 27
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8250
Mailing Address - Country:US
Mailing Address - Phone:907-561-5335
Mailing Address - Fax:907-654-7429
Practice Address - Street 1:43335 KALIFORNSKY BEACH RD STE 27
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8250
Practice Address - Country:US
Practice Address - Phone:907-561-5335
Practice Address - Fax:907-654-7429
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator