Healthcare Provider Details

I. General information

NPI: 1215155213
Provider Name (Legal Business Name): MARY ELLEN DOTY N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15765 KINGSLEY ROAD
NINILCHIK AK
99639-9759
US

IV. Provider business mailing address

PO BOX 39558
NINILCHIK AK
99639-0558
US

V. Phone/Fax

Practice location:
  • Phone: 907-567-3970
  • Fax:
Mailing address:
  • Phone: 907-235-8301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number351
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: