Healthcare Provider Details

I. General information

NPI: 1598806531
Provider Name (Legal Business Name): DAWN P MATHIS CSTCFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2007
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 OGDEN AVE SUITE 210
AURORA IL
60504-5894
US

IV. Provider business mailing address

1604 VISA DR STE 2
NORMAL IL
61761-2195
US

V. Phone/Fax

Practice location:
  • Phone: 630-585-0200
  • Fax:
Mailing address:
  • Phone: 309-454-7348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number237.000006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: