Individual
DAWN NICOLE LONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
11723 WOLF CREEK LN, PLAINFIELD, IL 60585-2504
(815) 557-7777
Mailing address
11723 WOLF CREEK LN, PLAINFIELD, IL 60585-2504
(815) 557-7777
Taxonomy
Speciality
Code
Description
License number
State
347C00000X
Private Vehicle
Primary
L520-1748-2799
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3000005
EI MCO
IL
Enumeration date
02/10/2017
Last updated
02/10/2017
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