Provider Demographics
NPI:1215155213
Name:DOTY, MARY ELLEN (NP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:DOTY
Suffix:
Gender:F
Credentials:NP
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 39558
Mailing Address - Street 2:
Mailing Address - City:NINILCHIK
Mailing Address - State:AK
Mailing Address - Zip Code:99639-0558
Mailing Address - Country:US
Mailing Address - Phone:907-235-8301
Mailing Address - Fax:
Practice Address - Street 1:15765 KINGSLEY ROAD
Practice Address - Street 2:
Practice Address - City:NINILCHIK
Practice Address - State:AK
Practice Address - Zip Code:99639-9759
Practice Address - Country:US
Practice Address - Phone:907-567-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKP49598Medicare UPIN