Healthcare Provider Details

I. General information

NPI: 1831571447
Provider Name (Legal Business Name): DAWN LYSNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 S 16TH ST
WILMINGTON NC
28401-4924
US

IV. Provider business mailing address

20 S 16TH ST
WILMINGTON NC
28401-4924
US

V. Phone/Fax

Practice location:
  • Phone: 910-399-3927
  • Fax: 910-399-3927
Mailing address:
  • Phone: 910-399-3927
  • Fax: 910-399-3927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28549
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: