Provider Demographics
NPI:1043612815
Name:DOTY, REANNON
Entity type:Individual
Prefix:
First Name:REANNON
Middle Name:
Last Name:DOTY
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:PO BOX 1567
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-0067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:815-489-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-353320163WR0006X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No163W00000XNursing Service ProvidersRegistered Nurse