Provider Demographics
NPI:1730270901
Name:ROSTAD HOLDMAN, NICOLE M (LRD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ROSTAD HOLDMAN
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:701-234-4111
Mailing Address - Fax:701-234-4130
Practice Address - Street 1:736 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4421
Practice Address - Country:US
Practice Address - Phone:701-234-4111
Practice Address - Fax:701-234-4130
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND705133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51262Medicaid
ND712158Medicare PIN