Provider Demographics
NPI:1629317292
Name:RISTAU, DAWN ELIZABETH (LAC)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:ELIZABETH
Last Name:RISTAU
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 N ATLANTA AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2011
Mailing Address - Country:US
Mailing Address - Phone:516-586-4364
Mailing Address - Fax:516-586-4364
Practice Address - Street 1:278 N ATLANTA AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2011
Practice Address - Country:US
Practice Address - Phone:516-586-4364
Practice Address - Fax:516-586-4364
Is Sole Proprietor?:No
Enumeration Date:2013-02-02
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004976-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist