Healthcare Provider Details

I. General information

NPI: 1558853515
Provider Name (Legal Business Name): ELIZABETH SUSAN DOTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 SILAS DEANE HWY
WETHERSFIELD CT
06109
US

IV. Provider business mailing address

77 LEE DR
SOUTHINGTON CT
06489-2926
US

V. Phone/Fax

Practice location:
  • Phone: 860-253-5330
  • Fax:
Mailing address:
  • Phone: 860-944-5849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7641
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: