Provider Demographics
NPI:1003629403
Name:LIFESPAN NP PSYCHIATRIC SERVICES, PC
Entity type:Organization
Organization Name:LIFESPAN NP PSYCHIATRIC SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:315-200-9723
Mailing Address - Street 1:1021 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2837
Mailing Address - Country:US
Mailing Address - Phone:315-200-9723
Mailing Address - Fax:
Practice Address - Street 1:60 E STATE ST STE 400
Practice Address - Street 2:
Practice Address - City:SHERRILL
Practice Address - State:NY
Practice Address - Zip Code:13461-1218
Practice Address - Country:US
Practice Address - Phone:315-200-9723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty