Provider Demographics
NPI:1902178890
Name:HANNON, DAWN MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:HANNON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6018 8TH AVENUE APT.1
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143
Mailing Address - Country:US
Mailing Address - Phone:262-412-8265
Mailing Address - Fax:
Practice Address - Street 1:1519 60TH STREET
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-3954
Practice Address - Country:US
Practice Address - Phone:262-656-7500
Practice Address - Fax:262-656-7500
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1785-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant