Provider Demographics
NPI:1215981667
Name:FROST, DAWN RENE (363L00000X)
Entity type:Individual
Prefix:MS
First Name:DAWN
Middle Name:RENE
Last Name:FROST
Suffix:
Gender:F
Credentials:363L00000X
Other - Prefix:MRS
Other - First Name:DAWN
Other - Middle Name:FROST
Other - Last Name:HADDOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:363L00000X
Mailing Address - Street 1:719 7TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-1935
Mailing Address - Country:US
Mailing Address - Phone:850-676-4287
Mailing Address - Fax:850-676-4292
Practice Address - Street 1:719 7TH ST
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-1938
Practice Address - Country:US
Practice Address - Phone:850-676-4287
Practice Address - Fax:850-676-4292
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAR2003622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY9052OtherBLUE CROSS/BLUE SHIELD
FL302899200OtherMEDIPASS
FL306088800Medicaid
FLP-03882Medicare UPIN
FLY9052AMedicare ID - Type Unspecified