Provider Demographics
NPI:1720456742
Name:DORMAN, SALLY ANN
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:DORMAN
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 1:316 MISSION RD
Mailing Address - Street 2:ROOM 207
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-7327
Mailing Address - Country:US
Mailing Address - Phone:907-486-3319
Mailing Address - Fax:907-486-8149
Practice Address - Street 1:316 MISSION RD
Practice Address - Street 2:ROOM 207
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-7327
Practice Address - Country:US
Practice Address - Phone:907-486-3319
Practice Address - Fax:907-486-8149
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK31220163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse