Provider Demographics
NPI:1467834457
Name:LOOMIS, DOREEN
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4851 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421-2124
Mailing Address - Country:US
Mailing Address - Phone:320-293-6116
Mailing Address - Fax:320-210-0438
Practice Address - Street 1:4851 2ND ST NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55421-2124
Practice Address - Country:US
Practice Address - Phone:320-293-6116
Practice Address - Fax:320-210-0438
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver