Healthcare Provider Details

I. General information

NPI: 1710801642
Provider Name (Legal Business Name): KAITLYN DORVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9817 SUZANNE CT STE A
WAXHAW NC
28173-6976
US

IV. Provider business mailing address

9817 SUZANNE CT STE A
WAXHAW NC
28173-6976
US

V. Phone/Fax

Practice location:
  • Phone: 704-412-4124
  • Fax: 704-246-7073
Mailing address:
  • Phone: 704-412-4124
  • Fax: 704-246-7073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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: