Basic Information
| Provider Information | |||||||||
| NPI: | 1194226910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORSEY | ||||||||
| FirstName: | SAHARA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BC-FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 424 WARDS CORNER RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451406966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137074041 | ||||||||
| FaxNumber: | 5135761020 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S 5TH ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451761017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136365005 | ||||||||
| FaxNumber: | 5134360470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2018 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 362755 | OH | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 022389 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0266639 | 05 | OH | MEDICAID |