Healthcare Provider Details

I. General information

NPI: 1114457892
Provider Name (Legal Business Name): DAWN KORSON D-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DAWN LONGCOR

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 07/21/2022
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD STE 1710
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-5859
  • Fax: 317-948-9939
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number3203046140
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.372695
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704251540
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.015571
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28235617A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: