Provider Demographics
NPI:1184662587
Name:DECOTIIS, DAWN ENNIS (FNP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:ENNIS
Last Name:DECOTIIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1638
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-1638
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:15 GRACELAWN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6334
Practice Address - Country:US
Practice Address - Phone:207-330-3950
Practice Address - Fax:207-330-3955
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME245200099Medicaid
MENP393504Medicare PIN
MENP3935Medicare PIN
MES86157Medicare UPIN