Provider Demographics
NPI:1336443944
Name:LYNGHOLM, EMILY MARGARET
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MARGARET
Last Name:LYNGHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MARGARET
Other - Last Name:JURGENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 35081
Mailing Address - Street 2:
Mailing Address - City:FT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-0081
Mailing Address - Country:US
Mailing Address - Phone:907-699-6557
Mailing Address - Fax:
Practice Address - Street 1:3039 DAVIS RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5234
Practice Address - Country:US
Practice Address - Phone:907-699-6557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-23
Last Update Date:2012-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK951770OtherDEPARTMENT OF COMMERCE, COMMUNITY, AND ECONOMIC DEVELOPMENT BUSINESS LICENSE