Healthcare Provider Details

I. General information

NPI: 1487137543
Provider Name (Legal Business Name): KATELYN DOTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 NEZ PERCE DR
LEWISTON ID
83501-4116
US

IV. Provider business mailing address

2102 NEZ PERCE DR
LEWISTON ID
83501-4116
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-4434
  • Fax: 208-743-9422
Mailing address:
  • Phone: 208-743-4434
  • Fax: 208-743-9422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number1225043342
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: