Provider Demographics
NPI:1366840431
Name:FUNK, DAWN
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 SPANGLER WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21205-3319
Mailing Address - Country:US
Mailing Address - Phone:410-227-7265
Mailing Address - Fax:
Practice Address - Street 1:7232 GERMAN HILL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-1260
Practice Address - Country:US
Practice Address - Phone:410-282-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAOOO1663172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker