Provider Demographics
NPI:1578923520
Name:HARRIS, DOROTHEA BRADY (CRNP)
Entity Type:Individual
Prefix:
First Name:DOROTHEA
Middle Name:BRADY
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:DOROTHEA
Other - Middle Name:BRADY
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12101 WOODCREST EXECUTIVE DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5047
Mailing Address - Country:US
Mailing Address - Phone:314-317-0600
Mailing Address - Fax:314-317-0606
Practice Address - Street 1:1720 KNOWLES RD
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36869-7135
Practice Address - Country:US
Practice Address - Phone:314-317-0600
Practice Address - Fax:314-317-0606
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-137711363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner