Provider Demographics
NPI:1659674893
Name:MACK, DAWN RAE
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:RAE
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DAWN
Other - Middle Name:RAE
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2104 55TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-3240
Mailing Address - Country:US
Mailing Address - Phone:941-727-7304
Mailing Address - Fax:941-756-0741
Practice Address - Street 1:2104 55TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3240
Practice Address - Country:US
Practice Address - Phone:941-727-7304
Practice Address - Fax:941-756-0741
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906357311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home