Provider Demographics
NPI:1760179691
Name:HART, DOREATIA LELIN (BSN, RN, PHN)
Entity Type:Individual
Prefix:MRS
First Name:DOREATIA
Middle Name:LELIN
Last Name:HART
Suffix:
Gender:F
Credentials:BSN, RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2009
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-2009
Mailing Address - Country:US
Mailing Address - Phone:209-468-0898
Mailing Address - Fax:
Practice Address - Street 1:16980 S HARLAN RD
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8738
Practice Address - Country:US
Practice Address - Phone:209-468-0898
Practice Address - Fax:209-774-2750
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA582958171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator