Provider Demographics
NPI:1215915996
Name:BEAUDRY, DAWN (PAC)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:BEAUDRY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:
Other - Last Name:RUCINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3800 HIGHLAND AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1558
Mailing Address - Country:US
Mailing Address - Phone:630-574-8222
Mailing Address - Fax:630-574-8225
Practice Address - Street 1:3800 HIGHLAND AVE STE 105
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1558
Practice Address - Country:US
Practice Address - Phone:630-574-8222
Practice Address - Fax:630-574-8225
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002223363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21959Medicare PIN
ILQ17294Medicare UPIN
IL212417Medicare PIN
IL501100Medicare PIN
ILK21960Medicare PIN