Provider Demographics
NPI:1134325764
Name:WANFALT, DAWN RENEE (ARNP, NNP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:RENEE
Last Name:WANFALT
Suffix:
Gender:F
Credentials:ARNP, NNP
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:RENEE
Other - Last Name:BEENBLOSSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2296
Mailing Address - Fax:319-356-4855
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2296
Practice Address - Fax:319-356-4855
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA085842363L00000X
IAK085842363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA70099OtherWELLMARK BCBS
IAI20519Medicare PIN