Provider Demographics
NPI:1538589759
Name:COULBOURNE, DAWNETTECOULBOURNE L I
Entity type:Individual
Prefix:
First Name:DAWNETTECOULBOURNE
Middle Name:L
Last Name:COULBOURNE
Suffix:I
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 1:4575 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3711
Mailing Address - Country:US
Mailing Address - Phone:330-931-2067
Mailing Address - Fax:
Practice Address - Street 1:4575 HAYES RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3711
Practice Address - Country:US
Practice Address - Phone:330-931-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-27
Last Update Date:2014-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH060689164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse