Provider Demographics
NPI:1235890559
Name:DORMAN, GERTRUDE
Entity Type:Individual
Prefix:
First Name:GERTRUDE
Middle Name:
Last Name:DORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21936 BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21936 BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5429
Practice Address - Country:US
Practice Address - Phone:941-467-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-08
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87-3948492OtherTAX IDENTIFICATION