Provider Demographics
NPI:1568936482
Name:WILDERMAN, DAWN N (LPN)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:N
Last Name:WILDERMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:N
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4241 HIGHWAY 14 W
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-1037
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:
Practice Address - Street 1:4241 HIGHWAY 14 W
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822-1037
Practice Address - Country:US
Practice Address - Phone:618-724-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043080119164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse