Healthcare Provider Details

I. General information

NPI: 1336353119
Provider Name (Legal Business Name): DEBORAH DOSTAL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 PINE ST
SOUTHBRIDGE MA
01550-1823
US

IV. Provider business mailing address

29 PINE ST
SOUTHBRIDGE MA
01550-1823
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-764-2462
Mailing address:
  • Phone: 508-765-9771
  • Fax: 508-764-2462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number231265
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: