Provider Demographics
NPI:1659681518
Name:ERICKSON, ENOLA JENAE
Entity Type:Individual
Prefix:
First Name:ENOLA
Middle Name:JENAE
Last Name:ERICKSON
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:PO BOX 593
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84091-0593
Mailing Address - Country:US
Mailing Address - Phone:801-819-1978
Mailing Address - Fax:
Practice Address - Street 1:7575 S 900 E
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2343
Practice Address - Country:US
Practice Address - Phone:801-208-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker