Provider Demographics
NPI:1417221334
Name:DORIS, MICAH JARRETT (RN, BSN)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:JARRETT
Last Name:DORIS
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 SOUTHWICK ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2515
Mailing Address - Country:US
Mailing Address - Phone:617-335-9779
Mailing Address - Fax:
Practice Address - Street 1:26 SOUTHWICK ST APT 1
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2515
Practice Address - Country:US
Practice Address - Phone:617-335-9779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA276465163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse