Healthcare Provider Details

I. General information

NPI: 1518181098
Provider Name (Legal Business Name): DAWN RENEE ANTLE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 E 10TH ST
JEFFERSONVILLE IN
47130-6016
US

IV. Provider business mailing address

1804 E 10TH ST
JEFFERSONVILLE IN
47130-6016
US

V. Phone/Fax

Practice location:
  • Phone: 812-288-2488
  • Fax: 812-288-6603
Mailing address:
  • Phone: 812-288-2488
  • Fax: 812-288-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002370A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002370A
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: