Provider Demographics
NPI:1528389962
Name:MASSEY, DAWN MARIE (NP-BC)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:MASSEY
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W AVON RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3678
Mailing Address - Country:US
Mailing Address - Phone:860-673-2581
Mailing Address - Fax:
Practice Address - Street 1:30 WEST AVON ROAD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001
Practice Address - Country:US
Practice Address - Phone:860-673-2581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004309363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1528389962Medicaid