Provider Demographics
NPI:1083952816
Name:ANDERSON, DAWNE R (APN)
Entity Type:Individual
Prefix:MS
First Name:DAWNE
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-1580
Mailing Address - Country:US
Mailing Address - Phone:773-413-1771
Mailing Address - Fax:773-413-1879
Practice Address - Street 1:5730 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-1580
Practice Address - Country:US
Practice Address - Phone:773-413-1771
Practice Address - Fax:773-413-1879
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010132363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209010132Medicaid