Basic Information
| Provider Information | |||||||||
| NPI: | 1902966674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOLE | ||||||||
| FirstName: | EVANGELINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 SPICER AVE | ||||||||
| Address2: | BOX 96 | ||||||||
| City: | RAYMOND | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 3202319140 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 6TH STREET SE | ||||||||
| Address2: | WOODLAND CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202319148 | ||||||||
| FaxNumber: | 3202319140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747P1801X | Y | Nursing Service Related Providers | Technician | Personal Care Attendant |
No ID Information.