Provider Demographics
NPI:1376751735
Name:VERNON, DAWN M (NP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:M
Last Name:VERNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5075
Mailing Address - Country:US
Mailing Address - Phone:815-397-7340
Mailing Address - Fax:815-397-7388
Practice Address - Street 1:401 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5075
Practice Address - Country:US
Practice Address - Phone:815-397-7340
Practice Address - Fax:815-397-7388
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006574363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1959013Medicare PIN
Q79132Medicare UPIN