=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588934186
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVA GRAHAM DAWSON PNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2012
-----------------------------------------------------
Last Update Date | 04/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 272 6TH AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10014-4721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-477-5316
-----------------------------------------------------
Fax | 646-661-2871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 453 FDR DRIVE C104
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-371-0323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 382256
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------