Provider Demographics
NPI:1932940731
Name:DOLTAIRE, GUY-EDGARD FOLLIVI (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:GUY-EDGARD
Middle Name:FOLLIVI
Last Name:DOLTAIRE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18310 MONTGOMERY VILLAGE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3552
Mailing Address - Country:US
Mailing Address - Phone:301-257-0726
Mailing Address - Fax:
Practice Address - Street 1:18310 MONTGOMERY VILLAGE AVE STE 300
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3552
Practice Address - Country:US
Practice Address - Phone:301-257-0726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR218458363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health