Provider Demographics
NPI:1104655356
Name:DORN, GERALYN CAROL
Entity type:Individual
Prefix:MRS
First Name:GERALYN
Middle Name:CAROL
Last Name:DORN
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 1:1217 LILLIAN ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1530
Mailing Address - Country:US
Mailing Address - Phone:262-613-2595
Mailing Address - Fax:
Practice Address - Street 1:1217 LILLIAN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1530
Practice Address - Country:US
Practice Address - Phone:262-613-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-27
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WID650-2836-1611-00385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care