Provider Demographics
NPI:1922403542
Name:LIDSTONE, DAWN LISA (FNP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:LISA
Last Name:LIDSTONE
Suffix:
Gender:F
Credentials:FNP
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 438
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01259-0438
Mailing Address - Country:US
Mailing Address - Phone:413-854-1815
Mailing Address - Fax:
Practice Address - Street 1:76 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2447
Practice Address - Country:US
Practice Address - Phone:860-624-0731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT087663163WG0000X
MA284722163WG0000X
NY679700-1163WG0000X
CT007744363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice