Healthcare Provider Details

I. General information

NPI: 1134439094
Provider Name (Legal Business Name): DAWN MARY RAINEY REGISTERED PROFESSIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DAWN MARY HAASE REGISTERED PROFESSIO

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 MOUNTAIN SPRING ROAD
MINEVILLE NY
12956
US

IV. Provider business mailing address

176 MOUNTAIN SPRING ROAD
MINEVILLE NY
12956
US

V. Phone/Fax

Practice location:
  • Phone: 518-572-5490
  • Fax: 518-942-3090
Mailing address:
  • Phone: 518-572-5490
  • Fax: 518-942-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number502270-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: