MEDICARE: DAWN ENNIS DECOTIIS FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP081531	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184662587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN ENNIS DECOTIIS FNP

Provider Business Mailing Address
First Line	:	PO BOX 1638
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12201-1638
Country	:	US
Telephone Number	:	207-777-4111
Fax Number	:	207-783-6660

Provider Business Practice Location Address
First Line	:	15 GRACELAWN RD
Second Line	:	SUITE 103
City	:	AUBURN
State	:	ME
Zip	:	04210-6334
Country	:	US
Telephone Number	:	207-330-3950
Fax Number	:	207-330-3955

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	07/04/2011

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