Basic Information
| Provider Information | |||||||||
| NPI: | 1043314271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUTTON | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP, CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1215 | ||||||||
| Address2: | 94125 4TH STREET | ||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974441215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412476628 | ||||||||
| FaxNumber: | 5412476629 | ||||||||
| Practice Location | |||||||||
| Address1: | 94125 4TH STREET | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412476628 | ||||||||
| FaxNumber: | 5412476629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 200650112NP FNP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LX0001X | 200150025NP NMNP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | P00420229 | 01 | OR | RAILROAD MEDICARE | OTHER | 278504 | 05 | OR | MEDICAID | 891095002 | 01 | OR | REGENCE BLUECROSS | OTHER |