Provider Demographics
NPI:1962772103
Name:AYCOCK, DAWN MARIE (APRN-C)
Entity type:Individual
Prefix:MS
First Name:DAWN
Middle Name:MARIE
Last Name:AYCOCK
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 NE 542ND ST
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32680-3818
Mailing Address - Country:US
Mailing Address - Phone:863-537-0644
Mailing Address - Fax:
Practice Address - Street 1:520 NE 542ND ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:FL
Practice Address - Zip Code:32680-3818
Practice Address - Country:US
Practice Address - Phone:863-537-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3191812363LF0000X
FLAPRN3191812363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004615000Medicaid