Provider Demographics
NPI:1255878815
Name:STADDON, DANA L (FNP-C)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:L
Last Name:STADDON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46801-2526
Mailing Address - Country:US
Mailing Address - Phone:260-436-8686
Mailing Address - Fax:
Practice Address - Street 1:7601 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4133
Practice Address - Country:US
Practice Address - Phone:260-436-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2024-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F1216399OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION
IN71011484AOtherIN APRN LICENSE
LAAP09146OtherLA APRN LICENSE