Provider Demographics
NPI:1477224723
Name:MIKETISH, DAWN MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:MARIE
Last Name:MIKETISH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2399 N UNION STREET EXT
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1574
Mailing Address - Country:US
Mailing Address - Phone:716-790-1584
Mailing Address - Fax:716-375-5190
Practice Address - Street 1:2399 N UNION STREET EXT
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1574
Practice Address - Country:US
Practice Address - Phone:716-790-1584
Practice Address - Fax:716-375-5190
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY721540163W00000X
PARN685701163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse