Provider Demographics
NPI:1093373490
Name:DOPWELL, JELISA KIMBERLY (NP)
Entity Type:Individual
Prefix:MISS
First Name:JELISA
Middle Name:KIMBERLY
Last Name:DOPWELL
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 1:36 WELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-1414
Mailing Address - Country:US
Mailing Address - Phone:516-713-6805
Mailing Address - Fax:
Practice Address - Street 1:7136 110TH ST SPC 1
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4850
Practice Address - Country:US
Practice Address - Phone:212-757-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308776363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health