=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831164755
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY LYNN DORFMAN ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 BURNETTS WAY STE 100
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-8168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-539-9333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1324 PETRELL DR
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-5673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-201-1782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 0126000900
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------