Healthcare Provider Details

I. General information

NPI: 1346599255
Provider Name (Legal Business Name): NICHOLETTE M ELEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICHOLETTE M GROSS LMT, CMLDT, E-RYT

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 W NORTHERN LIGHTS BLVD, SUITE 800
ANCHORAGE AK
99503
US

IV. Provider business mailing address

188 W NORTHERN LIGHTS BLVD, SUITE 800
ANCHORAGE AK
99503
US

V. Phone/Fax

Practice location:
  • Phone: 907-276-2803
  • Fax: 907-278-8052
Mailing address:
  • Phone: 907-276-2803
  • Fax: 907-278-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMP2111
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number102001
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: