Healthcare Provider Details

I. General information

NPI: 1114531316
Provider Name (Legal Business Name): DANA DEARBORN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 COURT ST
KEENE NH
03431-1718
US

IV. Provider business mailing address

8 NORMAN AVE
CHARLESTOWN NH
03603-4722
US

V. Phone/Fax

Practice location:
  • Phone: 603-354-5400
  • Fax:
Mailing address:
  • Phone: 603-892-9381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1500
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: