Provider Demographics
NPI:1164745147
Name:DORTMAN, TERIENNE R (CRNA)
Entity Type:Individual
Prefix:
First Name:TERIENNE
Middle Name:R
Last Name:DORTMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3280
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93278-3280
Mailing Address - Country:US
Mailing Address - Phone:757-319-8570
Mailing Address - Fax:
Practice Address - Street 1:1500 S MOONEY BLVD STE 5
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-4456
Practice Address - Country:US
Practice Address - Phone:757-319-8570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA104668Medicare PIN