Healthcare Provider Details

I. General information

NPI: 1174054324
Provider Name (Legal Business Name): ERIN EIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 KENYON RD
FORT DODGE IA
50501-5740
US

IV. Provider business mailing address

109 BRITSON CIR
ROLAND IA
50236-1013
US

V. Phone/Fax

Practice location:
  • Phone: 515-573-3101
  • Fax:
Mailing address:
  • Phone: 515-297-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA115491
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA115491
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: