Basic Information
| Provider Information | |||||||||
| NPI: | 1003867474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOTY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1081 N CHINA LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553130 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 N CHINA LAKE BLVD STE 190 | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604993855 | ||||||||
| FaxNumber: | 7604993870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 14159 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 163WE0003X | 404396 | CA | N | Nursing Service Providers | Registered Nurse | Emergency | 363L00000X | 7673 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | 2319 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.