Basic Information
| Provider Information | |||||||||
| NPI: | 1275130858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | NICHOL | ||||||||
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| OtherLastName: | GOLDBERG | ||||||||
| OtherFirstName: | DAWN | ||||||||
| OtherMiddleName: | NICHOL | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8285 BISHOP RD | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481168308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488820002 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 43825 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481882551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343973088 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2020 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704331894 | MI | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 892413341 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |