Healthcare Provider Details

I. General information

NPI: 1740408780
Provider Name (Legal Business Name): DAWN MARIE COULTHURST MASON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 POLO RD
WINSTON SALEM NC
27106-3831
US

IV. Provider business mailing address

1615 POLO RD
WINSTON SALEM NC
27106-3831
US

V. Phone/Fax

Practice location:
  • Phone: 336-722-7266
  • Fax: 336-201-0538
Mailing address:
  • Phone: 336-722-7226
  • Fax: 366-201-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5002208
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5002208
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5002208
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: