Provider Demographics
NPI:1902952666
Name:ROSACKER, DAWN ELIZABETH (CPHT,CMF,COF)
Entity type:Individual
Prefix:MISS
First Name:DAWN
Middle Name:ELIZABETH
Last Name:ROSACKER
Suffix:
Gender:F
Credentials:CPHT,CMF,COF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 PLAINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:JEWETT CITY
Mailing Address - State:CT
Mailing Address - Zip Code:06351-1025
Mailing Address - Country:US
Mailing Address - Phone:860-376-1200
Mailing Address - Fax:
Practice Address - Street 1:318 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5413
Practice Address - Country:US
Practice Address - Phone:860-889-8785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC22508225000000X
CT183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Not Answered183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTOR4680OtherHEALTHNET
CT00405699-00OtherBLUECARE FAMILY PLAN
CT12DME0121CT01OtherANTHEM BLUE CROSS
CT12DME0121CT01OtherANTHEM BLUE CROSS