Healthcare Provider Details

I. General information

NPI: 1215910641
Provider Name (Legal Business Name): NANCY COZETTE EKELUND OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7355 BLACK BUTTE RD # 2A
SHINGLETOWN CA
96088-9478
US

IV. Provider business mailing address

7355 BLACK BUTTE RD # 2A
SHINGLETOWN CA
96088-9478
US

V. Phone/Fax

Practice location:
  • Phone: 530-387-5499
  • Fax: 530-212-3724
Mailing address:
  • Phone: 530-515-7753
  • Fax: 530-212-3724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7944TPG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: