Provider Demographics
NPI:1972722262
Name:DORMAN, ANGELIQUE RENEE (PT)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:RENEE
Last Name:DORMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANGELIQUE
Other - Middle Name:RENEE
Other - Last Name:AUBUCHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:
Practice Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6691
Practice Address - Country:US
Practice Address - Phone:480-706-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1424225100000X
AZLPT-001877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist