Healthcare Provider Details

I. General information

NPI: 1407033467
Provider Name (Legal Business Name): ALLA A DODATKO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 GRANT AVE
PHILADELPHIA PA
19115-3160
US

IV. Provider business mailing address

9132 OLD NEWTOWN RD APT B8
PHILADELPHIA PA
19115-4917
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-3838
  • Fax: 215-464-3899
Mailing address:
  • Phone: 215-677-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number587631-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: