Healthcare Provider Details

I. General information

NPI: 1174746499
Provider Name (Legal Business Name): DAWN FAIRLIE ANP,GNP,FNP,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4771 HYLAN BLVD
STATEN ISLAND NY
10312-6315
US

IV. Provider business mailing address

4771 HYLAN BLVD
STATEN ISLAND NY
10312-6315
US

V. Phone/Fax

Practice location:
  • Phone: 973-216-9898
  • Fax:
Mailing address:
  • Phone: 973-216-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number314022-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number26NN06671900
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberF300719-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberF340111-1
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number26NN06671900
License Number StateNJ
# 6
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF332587-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: