Provider Demographics
NPI:1043645393
Name:SAMPLE, DAWNYELLE (CPHT)
Entity Type:Individual
Prefix:MS
First Name:DAWNYELLE
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 OAKMONT AVE
Mailing Address - Street 2:APT. 1
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5981
Mailing Address - Country:US
Mailing Address - Phone:443-683-9369
Mailing Address - Fax:
Practice Address - Street 1:421 THE FALLSWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202
Practice Address - Country:US
Practice Address - Phone:410-962-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT12509183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician