Provider Demographics
NPI:1396147377
Name:DERKS, DAWN MARIE (ACNS-BC, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:DERKS
Suffix:
Gender:F
Credentials:ACNS-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3626
Mailing Address - Country:US
Mailing Address - Phone:715-685-5500
Mailing Address - Fax:715-682-4022
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-21
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2014005854364SA2200X
WI15001-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02467OtherMEDICARE