Provider Demographics
NPI:1598965436
Name:MARTIN, DAWN ANN
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 501
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-0501
Mailing Address - Country:US
Mailing Address - Phone:631-473-6953
Mailing Address - Fax:
Practice Address - Street 1:211 MAIN ST
Practice Address - Street 2:APT 2
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1651
Practice Address - Country:US
Practice Address - Phone:631-473-6953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY420854-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse