Provider Demographics
NPI:1609449289
Name:DORTCH, AMBER JOELLE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:JOELLE
Last Name:DORTCH
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 1:5326 WILLOWBEND TRL
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9577
Mailing Address - Country:US
Mailing Address - Phone:517-974-9616
Mailing Address - Fax:
Practice Address - Street 1:5326 WILLOWBEND TRL
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-9577
Practice Address - Country:US
Practice Address - Phone:517-974-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704251428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily