1134325764 NPI number — DAWN RENEE WANFALT ARNP, NNP

Table of content: DAWN RENEE WANFALT ARNP, NNP (NPI 1134325764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134325764 NPI number — DAWN RENEE WANFALT ARNP, NNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANFALT
Provider First Name:
DAWN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP, NNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEENBLOSSOM
Provider Other First Name:
DAWN
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134325764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HAWKINS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IOWA CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52242-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-356-2296
Provider Business Mailing Address Fax Number:
319-356-4855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HAWKINS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52242-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-356-2296
Provider Business Practice Location Address Fax Number:
319-356-4855
Provider Enumeration Date:
06/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  085842 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0000X , with the licence number: K085842 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 70099 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com