Provider Demographics
NPI:1376854497
Name:NYSEWANDER, DORETTE MARIE (EDD)
Entity Type:Individual
Prefix:DR
First Name:DORETTE
Middle Name:MARIE
Last Name:NYSEWANDER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 MARGARET ST
Mailing Address - Street 2:STE 302 PMB 342
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3868
Mailing Address - Country:US
Mailing Address - Phone:904-859-1425
Mailing Address - Fax:
Practice Address - Street 1:3600 WINDMEADOWS BLVD.
Practice Address - Street 2:#97
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608
Practice Address - Country:US
Practice Address - Phone:904-859-1425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 101Y00000X, 101YS0200X, 133N00000X, 133NN1002X, 171M00000X, 172V00000X
FL174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker