Provider Demographics
NPI:1942445960
Name:HICOK, DAWN MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:MARIE
Last Name:HICOK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:MARIE
Other - Last Name:WALDERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 LIKENS LANE
Mailing Address - Street 2:
Mailing Address - City:LONGVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56655
Mailing Address - Country:US
Mailing Address - Phone:218-820-1365
Mailing Address - Fax:
Practice Address - Street 1:106 NORTH 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL67040-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse