Provider Demographics
NPI:1063572154
Name:FINICUM, DORTHEA JEANETTE
Entity type:Individual
Prefix:MRS
First Name:DORTHEA
Middle Name:JEANETTE
Last Name:FINICUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:PAULDEN
Mailing Address - State:AZ
Mailing Address - Zip Code:86334-0098
Mailing Address - Country:US
Mailing Address - Phone:928-636-0505
Mailing Address - Fax:
Practice Address - Street 1:2150 MONTE VISTA
Practice Address - Street 2:
Practice Address - City:PAULDEN
Practice Address - State:AZ
Practice Address - Zip Code:96334
Practice Address - Country:US
Practice Address - Phone:928-636-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8A4763OtherAHCCCS