Provider Demographics
NPI:1790393015
Name:VON HOLLE, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:VON HOLLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADDY
Other - Middle Name:
Other - Last Name:VON HOLLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3870
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-3870
Mailing Address - Country:US
Mailing Address - Phone:907-841-8376
Mailing Address - Fax:
Practice Address - Street 1:984 N MERIDIAN PL
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7215
Practice Address - Country:US
Practice Address - Phone:907-631-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1639702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer