Provider Demographics
NPI:1356992549
Name:EKLUND, NICOLE J
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:EKLUND
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 1:1035 AIRPORT DR
Mailing Address - Street 2:
Mailing Address - City:EAST TAWAS
Mailing Address - State:MI
Mailing Address - Zip Code:48730-9763
Mailing Address - Country:US
Mailing Address - Phone:989-310-1603
Mailing Address - Fax:
Practice Address - Street 1:1035 AIRPORT DR
Practice Address - Street 2:
Practice Address - City:EAST TAWAS
Practice Address - State:MI
Practice Address - Zip Code:48730-9763
Practice Address - Country:US
Practice Address - Phone:989-310-1603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002972235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist