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General NPI Number Information
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NPI Number | 1003629403
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Entity Type | Organization
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Legal Business Name | LIFESPAN NP PSYCHIATRIC SERVICES, PC
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Dates
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Enumeration Date | 01/29/2025
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | 60 E STATE ST STE 400
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City | SHERRILL
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State | NY
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Zip | 13461-1218
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Country | US
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Telephone | 315-200-9723
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Fax |
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Provider Business Mailing Address
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Address Line | 1021 CHAPEL ST
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City | ONEIDA
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State | NY
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Zip | 13421-2837
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Country | US
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Telephone | 315-200-9723
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Fax |
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Authorized Official
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Title or Position | OWNER, PRESIDENT
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Name | KELLY DORMAN
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Credential | NP
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Telephone | 315-200-9723
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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