MEDICARE: MRS. MELINDA CECILE EKHOLM ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP30005591	WA
2	363LP2300X	Primary Care Nurse Practitioner	RN00082739	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	143010	OTHER	WA	LABOR & INDUSTRIES ID #

General Provider Information

NPI Number	:	1912008988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELINDA CECILE EKHOLM ARNP

Provider Business Mailing Address
First Line	:	3994 COLVILLE RD
Second Line	:	PO BOX 303
City	:	LOON LAKE
State	:	WA
Zip	:	99148-9789
Country	:	US
Telephone Number	:	509-233-8412
Fax Number	:	509-233-2864

Provider Business Practice Location Address
First Line	:	3994 COLVILLE RD
Second Line	:
City	:	LOON LAKE
State	:	WA
Zip	:	99148-9789
Country	:	US
Telephone Number	:	509-233-8412
Fax Number	:	509-233-2864

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	03/31/2008

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