Provider Demographics
NPI:1669421335
Name:WALLACE, DAWN L (RN)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:LOUISE
Other - Last Name:GEBOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:18595 BROOKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-1026
Mailing Address - Country:US
Mailing Address - Phone:262-894-3880
Mailing Address - Fax:262-754-0690
Practice Address - Street 1:18595 BROOKRIDGE DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-1026
Practice Address - Country:US
Practice Address - Phone:262-894-3880
Practice Address - Fax:262-754-0690
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38214700Medicaid