Provider Demographics
NPI:1396881819
Name:TRAVELSTEAD, DAWN AMY (LPN)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:AMY
Last Name:TRAVELSTEAD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 DALE ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1404
Mailing Address - Country:US
Mailing Address - Phone:618-610-9689
Mailing Address - Fax:
Practice Address - Street 1:988 N ILLINOIS ROUTE 3
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1000
Practice Address - Country:US
Practice Address - Phone:618-939-4444
Practice Address - Fax:618-939-4181
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0043069901164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse