Provider Demographics
NPI:1033615919
Name:DAWSON, KELLEN
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:
Last Name:DAWSON
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 1:407 W OAK CIR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7532
Mailing Address - Country:US
Mailing Address - Phone:337-654-1478
Mailing Address - Fax:
Practice Address - Street 1:3120 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4219
Practice Address - Country:US
Practice Address - Phone:800-685-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-01
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program