Provider Demographics
NPI:1336775931
Name:DOLL, ELISE JOHANSON (CNM)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:JOHANSON
Last Name:DOLL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:KIRSTEN
Other - Last Name:JOHANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:ABINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19001-3788
Mailing Address - Country:US
Mailing Address - Phone:215-481-2000
Mailing Address - Fax:
Practice Address - Street 1:1200 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3720
Practice Address - Country:US
Practice Address - Phone:215-481-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010570367A00000X
NJ25ME00071401367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMW010570OtherCNM LICENSE