Basic Information
| Provider Information | |||||||||
| NPI: | 1306822895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VOLD | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA,CCC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSELAND | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA,CCC-A | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1215 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152394480 | ||||||||
| FaxNumber: | 5152394539 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152394480 | ||||||||
| FaxNumber: | 5152394539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 00475 | IA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 0448464 | 05 | IA | MEDICAID |