Basic Information
| Provider Information | |||||||||
| NPI: | 1578923520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | DOROTHEA | ||||||||
| MiddleName: | BRADY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HOLT | ||||||||
| OtherFirstName: | DOROTHEA | ||||||||
| OtherMiddleName: | BRADY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12101 WOODCREST EXECUTIVE DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 KNOWLES RD | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368697135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2016 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1-137711 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.