Provider Demographics
NPI:1154786614
Name:BROCKETT, DAWN RENAE
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:RENAE
Last Name:BROCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:RENAE
Other - Last Name:SMAIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:2459 SE TUALATIN VALLEY HWY # 416
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-7919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1535 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4345
Practice Address - Country:US
Practice Address - Phone:866-972-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4332363LF0000X
OR201805045NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily