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NPI Code Detail

MEDICARE: ELIZABETH GRACE DOELLER ATC, EMT-B

MEDICARE: ELIZABETH GRACE DOELLER ATC, EMT-B
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer2000053256
2390200000XStudent in an Organized Health Care Education/Training Program

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12000053256OTHERCERTIFIED ATHLETIC TRAINER
2B202000367OTHERVAEMT

General Provider Information

NPI Number : 1588318836
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELIZABETH GRACE DOELLER ATC, EMT-B
Provider Business Mailing Address
First Line : 3912 41ST ST W
Second Line :
City : BRADENTON
State : FL
Zip : 34205-2327
Country : US
Telephone Number : 571-232-8463
Fax Number :
Provider Business Practice Location Address
First Line : 5650 BOLLETTIERI BLVD
Second Line :
City : BRADENTON
State : FL
Zip : 34210-2211
Country : US
Telephone Number : 800-872-6425
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/07/2022
Last Update Date : 12/15/2025

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