Provider Demographics
NPI:1588318836
Name:DOELLER, ELIZABETH GRACE (ATC, EMT-B)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:DOELLER
Suffix:
Gender:F
Credentials:ATC, EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6336 WILLINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018
Mailing Address - Country:US
Mailing Address - Phone:571-232-8463
Mailing Address - Fax:
Practice Address - Street 1:6336 WILLINGHAM DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:571-232-8463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000532562255A2300X
390200000X
VAB202000357146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000053256OtherCERTIFIED ATHLETIC TRAINER
VAB202000367OtherEMT