Healthcare Provider Details

I. General information

NPI: 1780198101
Provider Name (Legal Business Name): KATELYN ELLEN DOLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 06/21/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 HALE ST
PRIDES CROSSING MA
01965-9800
US

IV. Provider business mailing address

143 CANAL ST APT 9
SALEM MA
01970-4603
US

V. Phone/Fax

Practice location:
  • Phone: 978-236-3010
  • Fax:
Mailing address:
  • Phone: 845-803-1181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3890
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2509
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: