Provider Demographics
NPI:1003944836
Name:THERKILDSEN, DANA SHAY (IDC)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:SHAY
Last Name:THERKILDSEN
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS JOHN C STENNIS CVN74
Mailing Address - Street 2:PO BOX 67
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOONE RD
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1894
Practice Address - Country:US
Practice Address - Phone:360-475-4887
Practice Address - Fax:360-475-4522
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710I1002XOtherINDEPENDENT DUTY CORPSMAN