Healthcare Provider Details

I. General information

NPI: 1720505795
Provider Name (Legal Business Name): DAWN RENEE LANDECK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 WASHINGTON AVE
TYRONE PA
16686-1426
US

IV. Provider business mailing address

8796 ROUTE 219
BROCKWAY PA
15824-6010
US

V. Phone/Fax

Practice location:
  • Phone: 814-684-0320
  • Fax:
Mailing address:
  • Phone: 814-265-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP017831
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: