Provider Demographics
NPI:1255154688
Name:DORESTANT, MARIE ITELA
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ITELA
Last Name:DORESTANT
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 1:733 WALTER WAY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1193
Mailing Address - Country:US
Mailing Address - Phone:701-934-4248
Mailing Address - Fax:
Practice Address - Street 1:733 WALTER WAY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1193
Practice Address - Country:US
Practice Address - Phone:701-934-4248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND59196376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide