Provider Demographics
NPI:1558834986
Name:BURRELL, DOROTHY CHADIKA
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:CHADIKA
Last Name:BURRELL
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 1:253 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-1215
Mailing Address - Country:US
Mailing Address - Phone:678-760-6321
Mailing Address - Fax:
Practice Address - Street 1:28168 OLD RAINIER RD
Practice Address - Street 2:
Practice Address - City:RAINIER
Practice Address - State:OR
Practice Address - Zip Code:97048-3017
Practice Address - Country:US
Practice Address - Phone:800-244-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN248381363LF0000X
WAAP61486147363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily