Provider Demographics
NPI:1912008988
Name:EKHOLM, MELINDA CECILE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:CECILE
Last Name:EKHOLM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:MELINDA
Other - Middle Name:C
Other - Last Name:ELLEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3994 COLVILLE RD
Mailing Address - Street 2:PO BOX 303
Mailing Address - City:LOON LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99148-9789
Mailing Address - Country:US
Mailing Address - Phone:509-233-8412
Mailing Address - Fax:509-233-2864
Practice Address - Street 1:3994 COLVILLE RD
Practice Address - Street 2:
Practice Address - City:LOON LAKE
Practice Address - State:WA
Practice Address - Zip Code:99148-9789
Practice Address - Country:US
Practice Address - Phone:509-233-8412
Practice Address - Fax:509-233-2864
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005591363LF0000X
WARN00082739363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9629320Medicaid
WA143010OtherLABOR & INDUSTRIES ID #
WAAB18588Medicare ID - Type UnspecifiedMEDICARE PART B ID NUMBER
WAAB18591Medicare ID - Type UnspecifiedMEDICARE PART B ID NUMBER
WAAB18590Medicare ID - Type UnspecifiedMEDICARE PART B ID NUMBER
WA501810Medicare Oscar/Certification
WAAB18589Medicare ID - Type UnspecifiedMEDICARE PART B ID NUMBER
WA9629320Medicaid
WAP23312Medicare UPIN
WAAB18549Medicare ID - Type UnspecifiedMEDICARE PART B ID NUMBER