Healthcare Provider Details

I. General information

NPI: 1841764073
Provider Name (Legal Business Name): REBECCA DOLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

PO BOX 1332
LAKE ARROWHEAD CA
92352-1332
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-1000
  • Fax:
Mailing address:
  • Phone: 909-496-6973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number583712
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95010250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: