Provider Demographics
NPI:1588318836
Name:DOELLER, ELIZABETH GRACE (ATC, EMT-B)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:DOELLER
Suffix:
Gender:F
Credentials:ATC, EMT-B
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3912 41ST ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-2327
Mailing Address - Country:US
Mailing Address - Phone:571-232-8463
Mailing Address - Fax:
Practice Address - Street 1:5650 BOLLETTIERI BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-2211
Practice Address - Country:US
Practice Address - Phone:800-872-6425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2025-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000532562255A2300X
390200000X
VAB202000357146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000053256OtherCERTIFIED ATHLETIC TRAINER
VAB202000367OtherEMT