Provider Demographics
NPI:1114078037
Name:ERICKSON, DANA LYNN (OTR)
Entity Type:Individual
Prefix:MS
First Name:DANA
Middle Name:LYNN
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:DANA
Other - Middle Name:LYNN
Other - Last Name:GULKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:813 LYNN ST
Mailing Address - Street 2:
Mailing Address - City:HORICON
Mailing Address - State:WI
Mailing Address - Zip Code:53032-1110
Mailing Address - Country:US
Mailing Address - Phone:920-485-0880
Mailing Address - Fax:
Practice Address - Street 1:611 MILL ST
Practice Address - Street 2:
Practice Address - City:HORICON
Practice Address - State:WI
Practice Address - Zip Code:53032-1461
Practice Address - Country:US
Practice Address - Phone:920-485-4423
Practice Address - Fax:920-485-4318
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI591-026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist