Provider Demographics
NPI:1164196457
Name:DORMEVIL, GARRY ROGER (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:ROGER
Last Name:DORMEVIL
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S STATE COLLEGE BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5814
Mailing Address - Country:US
Mailing Address - Phone:805-719-3700
Mailing Address - Fax:805-413-9099
Practice Address - Street 1:79440 CORPORATE CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7243
Practice Address - Country:US
Practice Address - Phone:805-719-3700
Practice Address - Fax:805-413-9099
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily