Provider Demographics
NPI:1982206058
Name:DUNN, KATELYN ROSE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:DUNN
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 1:5592 BAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4102
Mailing Address - Country:US
Mailing Address - Phone:330-509-1828
Mailing Address - Fax:
Practice Address - Street 1:5592 BAYLOR AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-4102
Practice Address - Country:US
Practice Address - Phone:330-509-1828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0423022376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000275115Medicaid