Provider Demographics
NPI:1235904442
Name:WILBURN, DAWN DENISE (LMT)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:DENISE
Last Name:WILBURN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480770 HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-7438
Mailing Address - Country:US
Mailing Address - Phone:208-627-9708
Mailing Address - Fax:
Practice Address - Street 1:480770 HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-7438
Practice Address - Country:US
Practice Address - Phone:208-627-9708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40307163W00000X
IDMASG-915225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty