Provider Demographics
NPI:1104178953
Name:WADE, DAWN (LPN)
Entity Type:Individual
Prefix:MS
First Name:DAWN
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8780 E MCKELLIPS RD LOT 475
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-4803
Mailing Address - Country:US
Mailing Address - Phone:775-379-8258
Mailing Address - Fax:
Practice Address - Street 1:15778 W YUMA RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3358
Practice Address - Country:US
Practice Address - Phone:623-932-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP041423164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse