Healthcare Provider Details

I. General information

NPI: 1588318836
Provider Name (Legal Business Name): ELIZABETH GRACE DOELLER ATC, EMT-B
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5650 BOLLETTIERI BLVD
BRADENTON FL
34210-2211
US

IV. Provider business mailing address

3912 41ST ST W
BRADENTON FL
34205-2327
US

V. Phone/Fax

Practice location:
  • Phone: 800-872-6425
  • Fax:
Mailing address:
  • Phone: 571-232-8463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000053256
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: