Provider Demographics
NPI:1114197605
Name:DAWSON, MILLICENT G (RN)
Entity type:Individual
Prefix:
First Name:MILLICENT
Middle Name:G
Last Name:DAWSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3856 BRONX BLVD
Mailing Address - Street 2:APT 6M
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-5200
Mailing Address - Country:US
Mailing Address - Phone:718-324-1053
Mailing Address - Fax:
Practice Address - Street 1:3856 BRONX BLVD
Practice Address - Street 2:APT 6M
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-5200
Practice Address - Country:US
Practice Address - Phone:718-324-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287200164W00000X
NY671560163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02888737Medicaid