Provider Demographics
NPI:1619490786
Name:DORN, HOLLY (SAPA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:DORN
Suffix:
Gender:F
Credentials:SAPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 WITTMANN DR
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-3607
Mailing Address - Country:US
Mailing Address - Phone:920-558-3600
Mailing Address - Fax:920-997-8170
Practice Address - Street 1:1125 WITTMANN DR
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-3607
Practice Address - Country:US
Practice Address - Phone:920-558-3600
Practice Address - Fax:920-997-8170
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center