Provider Demographics
NPI:1821622820
Name:DODDS, POLLY CHRYSANTHEMUM
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:CHRYSANTHEMUM
Last Name:DODDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:CHRYSANTHEMUM
Other - Last Name:BEUKERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:430 SAWMILL CREEK RD UNIT 6
Mailing Address - Street 2:
Mailing Address - City:COPPEROPOLIS
Mailing Address - State:CA
Mailing Address - Zip Code:95228-9242
Mailing Address - Country:US
Mailing Address - Phone:209-785-7000
Mailing Address - Fax:209-785-7025
Practice Address - Street 1:430 SAWMILL CREEK RD UNIT 6
Practice Address - Street 2:
Practice Address - City:COPPEROPOLIS
Practice Address - State:CA
Practice Address - Zip Code:95228-9242
Practice Address - Country:US
Practice Address - Phone:209-785-7000
Practice Address - Fax:209-785-7025
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95013962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily