Provider Demographics
NPI:1174747505
Name:GUNDERSON, DAWN MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:MARIE
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR STE 400
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:10701 ALLIANCE DR STE A
Practice Address - Street 2:
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-8837
Practice Address - Country:US
Practice Address - Phone:317-856-7083
Practice Address - Fax:317-856-7332
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001314A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN277402EMedicare PIN
INP52853Medicare UPIN